Ml    ESfcJAX    Ja    Ni£UJi&iJUrlA 


^>RCA\7. 


B5£> 


Columbia  tttitottrftp 

College  of  pbpstctans  anb  burgeons 
XLtbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/essayonneuralgiaOOmurr 


MH-OL^^^oV^     YV  "^j 


AN    ESSAY 


ON 


NEURALGIA 


SECOND   VICE-PrISs 
MEMBER 


BY  J OM&*t.tJB;  MURRAY,  A.  31. 

ifl^TP^1    THE  AMERftWjfry^lft 

r  ofV( 


PIAN   SOCIETY,  ANI> 
OLTJMBIA  COLLEGE. 


NEW-YORK  : 

fRINTED  BY  J.  SEYMOUR,  No.  49  JOHN-STREET. 


1B1G, 


A 


/m 


AN 


INAUGURAL  DISSERTATION 


ON 


NEURALGIA, 


SUBMITTED    TO    THE    PUBLICS    EXAMINATION    OE    THE 


TRUSTEES  OF  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS, 


OF  THE  UNIVERSITY  OF  THE  STATE  OF  NEW-YORK, 


SAMUEL  BARD,  M.  D.  PRESIDENT, 


THE  DEGREE  OF  DOCTOR  OF  MEDICINE; 


MONDAY  THE  SIXTH  DAY  OF  MAY,  1816, 


I 


TO 
WRIGHT  POST,  M.  D. 

PROFESSOR  OE  ANATOMY,  PHYSIOLOGY,  AND  SURGERY,  IN  THE  COLLEGE 
OF  PHYSICIANS  AND  SURGEONS  ; 

VALENTINE  MOTT,  M.  D. 

PROFESSOR  OE  THE  PRINCIPLES  AND  OPERATIONS  OE  SURGERY  ; 

DAVID  HOSACK,  M.  D.  F.  L.  S. 

PROFESSOR  OE  THE  THEORY  AND  PRACTICE  OE  PH  YSICK,  AND  OF  MIDWIFERY  ; 

SAMUEL  L.  MITCHILL,  M.  D.  F.  R.  S.  Ed. 

PROFESSOR  OE  NATURAL  HISTORY  ; 

WILLIAM  JAMES  M'NEVEN,  M.  D. 

PROFESSOR    OE    CHEMISTRY   AND    MATERIA   MEDICA  \ 

JAMES  S.  STRINGHAM,  M.  D. 

PROFESSOR   OF    MEDICAL   JURISPRUDENCE  : 

NO  LESS  IN  ADMIRATION  OF  THEIR  ABILITIES  AND  LEARNING, 

THAN  IN  GRATITUDE  FOR  THEIR  NUMEROUS  DISPLAYS  OF  PROFESSIONAL 
AND  PERSONAL  KINDNESS, 

THIS 

INAUGURAL  DISSERTATION 

IS 

RESPECTFULLY  DEDICATED, 

BY  THEIR  MUCH  OBLIGED  PUPIL, 

JOHN  WILLIAM  BOYLES  MURRAY, 


Q 


A^  j*.  9:  Mz^,. 


^&CJ$3(A 


M18TOMY, 


The  disease  which  the  French  first  called  Tic 
douloureux,  and  which  has  been  generally  styled 
by  that  name.,  in  preference  to  Dr.  FotherguTs 
more  undefined  appellation  of  u  A  painful 
affection  of  the  face/'  has  been  scarcely  noticed 
by  ancient  writers.  It  wras  so  little  heeded  by 
modern  physicians,  that  when  that  excellent 
practitioner  invited  the  attention  of  his  brethren 
to  its  existence,  he  was  considered  as  its  first 
describer. 

Much  doubt  has  been  expressed  concerning 
the  meaning  and  origin  of  the  word  tic.  Sau- 
sages has  a  species  Trismus  equinus  gallice  le 
Tic.  Sic  dicitur  quia  equi  hoc  affectu  labo- 
rantes  dentibus  prcesepium  impetunt  et  sonum 
Tic  referunt*.  Under  the  eighth  species,  Tris- 
mus hypochondriacus \  he  observes,  hue  referri 
potest  distortio  musculorum  genets,  oculos  Sf 
maxillam  moventium  involuntarid  et  pravo 
usu  assueta,  quae  vulgo  Tic  dicitur.  The 
same  explanation  of  the  term  is  given  in  the 

*  Nosologia  Methodica,  Class  IV.  ii.  6. 


£  8 
dictionaries  of  the  Academy,  Boiste  and  Cham- 
baud.  The  singular  affection  of  horses,  during 
which  they  strike'  their  teeth  together  while 
biting  at  the  manger,  and  the  unseemly  habits 
of  twisting  the  face,  eyes,  and  lower  jaw,  in 
which  some  persons  indulge,  are  therefore  the 
roots  of  this  expression.  The  term  tic  doulou- 
reux is  the  ingenious  application  of  forcible 
expressions  used  in  common  life  to  an  acute 
disease,  which  to  the  superficial  observer  seems 
to  partake  of  two  analogous  affections. 

Besides  the  terms  tic  douloureux  and  pain- 
ful affection  of  the  face  of  Dr.  Fothergill,  it 
has  been  yariously  styled  by  different  writers, 
Trismus  dolorificus ,  Tic  convulsif.,  Morbus 
nervorum  faciei  crucians^  Prosophalgia, 
Aerophobia,  8$c.  But  since  these  expressions 
by  no  means  specify  the  seat  nor  nature  of  the 
disorder,  the  generick  term  neuralgia,  recom- 
mended by  Professor  Chaussier,  is  certainly 
the  most  correct,  classical,  and  comprehensive. 
According  to  its  situation  in  the  system,  it  may 
be  specifically  distinguished  as  Neuralgia  faciei, 
brachii,  digiti,  <fyc.  Banishing  the  unscientifick 
language  hitherto  employed,  with  the  approba- 
tion of  many  learned  and  eminent  physicians, 
the  disease  should  henceforward  be  designated 
and  acknowledged  only  as  neuralgia. 

In  detailing  the  records  of  Neuralgia,  after 
giving  due  credit  to  the  more  ancient  writers. 


the  medical  men  of  the  present  day  seem  to 
consider  Dr.  John  Fothergill"  as  its  principal 
discoverer.  The  notices  of  Neuralgia  anions 
modern  physicians  have  been  numerous,  but 
none  have  given  a  sy  sterna  tick  view  of  it, 
specifying  all  the  methods  of  management, 
and  especially,  as  connected  with  the  various 
surgical  operations  now  recommended  for  its 
relief. 

The  Greeks  are  perfectly  silent  concerning 
it ;  but  it  is  said  to  have  been  mentioned  by 
Rhazes,  the  celebrated  Arabian,  whose  descrip- 
tion he  acknowledges  to  have  been  derived  from 
Simion  Seth,  physician  to  an  Eastern  Emperor, 
during  the  eleventh  century.  "  Subsequent  to 
this  period,  Ebr  Sina,  of  the  same  nation,  de- 
scribed the  disease,  more  fully  and  with  more 
precision6."  From  the  investigation  which 
has  been  bestowed  on  this  subject,  it  appears 
that,  John  Hartmann  Degener,  a  physician  of 
Nimeguen,  in  1724,  is  next  entitled  to  the  dis- 
tinction of  having  given  the  most  circumstantial 
account  of  Neuralgia'.      Dr.   Siebold^  whose 


a  Med.  Observ.  and  Inq.  vol.  v. 

b  New  England  Journal  of  Medicine  and  Surgery,  vol.  ii.  p.  115.  Dr.  Jack- 
son on  Tic  douloureux. 

c  Acta  Naturae  Curios.  u  De  dolore  quodam  perraro  acerboque  maxillae 
•sinistra?  partes  occupante,  et  per  paroxysmos  recurrente."     vol.  i.  347. 

d  Doloris  Faciei,  niorbi  rarioris  atque  atrocis  observationibus  Olastrati 
adurnbratio  Diatribe  I.  qua  exercitationes  clinicas  in  nosocomio  juliaeo,  ha- 
bendas  indicit  G.  Ch.  Siebold,  Dr.  Med.  Prof.  Wirceburgi  1795.  Diatribe  II. 
1797.     Translated  in  the  Medical  and  Phvsical  Journal.  No.  SO. 

2 


10 

research  has  been  practical  and  laborious,  meti-* 
tions  that  in  1673,  observations  on  this  disease 
were  published  by  Dr.  Daniel  Ludwige.  Pos- 
terior to  these  publications,  N.  Andre/,  a  surgeon 
of  Versailles,  in  his  observations  on  the  diseases 
of  the  urethra,  has  some  remarks  on  Tic  clou- 
loureux ;  to  him  this  appellation  is  traced, 
and  it  has  been  adopted  in  common  parlance 
and  formal  treatises  since  his  time.  In  the 
edition  of  Sauvages7  Nosologia  Methodica,  1763, 
that  illustrious  physician  gives  a  character  of  the 
disease  under  the  title  of  Trismus  dolorificus, 
particularly  notices  the  deceptive  nature  of  its 
symptoms,  and  prescribes  caustick  or  division 
of  the  nerve,  as  the  certain  cure. 

As  before  stated,  the  philanthropick  Fother- 
gill  embellished  the  subject  by  his  clear  and 
practical  description  of  the  disease,  of  which 
he  professed  to  know  no  more  than  what  had 
occurred  to  him  in  his  private  practice.  The  fond 
national  partiality  of  his  countrymen  emblaz- 
oned Dr.  FothergiU's  reputation  as  the  disco- 
verer of  a  new  disease,  and  with  his  brief  his- 
tory, the  inquiry  in  England  rested,  The  im- 
possibility of  obtaining  the  works  in  which  the 
labours  of  his  predecessors  are  registered,  is  my 


e  Misc.  Nat.  Cur.  Dec.  i.  Ann  iii.  Observ.  252.  "  De  dolore  superciliari 
acerbissimo.1' 

/  Diagnos.  Med.  et  Recueil  period,  de  la  Soc.  de  Med.  de  Paris,  1756,  tome 
iv.  p.  318.  "  Observations  pratiques  des  maladies  de  l'urethre  et  sur  les  plusiers 
faits  convulsifs." 


n  m 

apology  for  the  imperfect  condition  in  which 
this  inquiry  is  necessarily  relinquished.  Fol- 
lowing Dr.  Fothergill  are  many  writers,  among 
w7hom,  the  principal  are  Messrs.  Thouret, 
Andry,  Pujol,  and  Richter.  Pujol's  essay  is 
said  to  exhibit  a  very  learned  and  laborious 
investigation  into  ancient  authorities,  for  the 
purpose  of  ascertaining  the  extent  of  ancient 
knowledge  and  observation. 

The  ingenious  Dr.  Haighton5  has  distinguish- 
ed  himself  by  the  interesting  view  which  he  has 
taken  of  Neuralgia,  and  of  its  surgical  treatment. 
Dr.  S.  Fothergill  has  also  written  a  systematick 
treatise  on  the  disease,  so  ably  illustrated  by  his 
lamented  uncle. 

To  the  unfrequent  appearance  of  Neuralgia, 
are  wTe  to  ascribe  the  slight  acquaintance  which 
many  physicians  of  eminence  have  acknow- 
ledged concerning  it.  Excepting  the  Italians, 
according  to  Dr.  Siebold,  writers  of  all  nations 
have  seen  cases  of  Neuralgia.  "  Dr.  Fother- 
gill met  with  sixteen  instances  of  it ;  Dr.  Thi- 
lenius,  a  German  physician,  saw  it  but  twTice 
during  a  most  extensive  practice  of  twenty 
years ;  Dr.  Aepli,  a  SwTiss  physician,  only 
once  in  twenty-seven  years."  In  America, 
of  late  years,  many  cases  have  been  recorded. 
Professor  Hosack  has  seen  six  cases ;  Dr.  Jack- 

g  Medical  Records  and  Researches. 


\ 


12 

"3on  details  his  treatment  of  four  patients ;  and 
Professor  Mott^  within  a  very  few  years,  has- 
been  instrumental  in  relieving  five  sufferers. 
Other  respectable  practitioners  in  different  parts 
of  the  union  have  borne  testimony  to  its  occur- 
rence, and  likewise  to  its  tractability ,  when  pro- 
perly and  actively  treated. 

As  to  the  greater  liability  to  this  disease  ex- 
hibited by  either  sex,  some  contrariety  of  opi- 
nion exists.  In  England,  females  have  been 
afflicted  with  Neuralgia  in  the  proportion  of  14 
to  1  male ;  while  in  Germany,  the  comparison 
of  frequency  is  21  men  to  13  women.  In 
America,  the  law  of  nervous  irritability  exposes 
females  to  the  occurrence  of  this  bane  of  com- 
fort, to  a  greater  degree  than  the  hardier  sex. 
All  Dr.  Jackson's  cases  were  ladies ;  but  Dr. 
Mott's  experience  inclines  rather  to  the  opposite 
opinion  :  only  two  of  his  patients  were  females, 
It  is  evident,  that  the  history  of  Neuralgia  is 
still  very  imperfect;  and  indeed  for  practical 
purposes  the  preceding  details  are  of  little  value, 
except  they  be  employed  to  convince  the  skep- 
tical, or  confirm  the  doubting. 

Dr.  J.  Fothergill  is  inclined  to  believe,  that 
the  disease  is  rather  an  attendant  on  advanced 
life,  than  on  an  earlier  period.  "  On  review- 
ing the  cases  mentioned  by  different  authors, 
we  observe,  that  they  were  for  the  most  part 


13  d 

confined  to  the  period  of  age  between  the 
thirtieth  and  eightieth  year;  and  instances  of 
the  disorder  being  met  with  at  an  earlier 
period  of  life  have  but  rarely  occurred." — - 
"  Fortsmann,  a  German  writer  quoted  with 
great  respect  by  Heurteloup\  says,  that  he 
has  seen  the  disease  in  young  girls  of  twenty, 
and  even  of  nine  years."  Heurteloup  also 
gives  a  long  and  minute  account  of  a  Corsican, 
wrho  was  under  thirty  years  of  age1.  Dr.  Dar- 
win, in  his  Zoonomia,  relates  a  case  unusually 
severe,  and  of  great  extent,  in  which  the  patient 
was  between  twenty  and  thirty  years  of  age. 

Connected  with  the  irregularity  of  appear- 
ance as  to  age  and  sex,  is  the  uncertainty  of  the 
temperament,  in  which  a  practitioner  may  ex- 
pect to  meet  with  Neuralgia.  Indeed  no  habit 
of  body  nor  of  life  seems  exempt  from  its 
attacks  :  the  laborious  and  the  indolent,  the 
phlegmatick  and  the  nervous,  the  rigid  fibre 
as  well  as  the  lax5  the  thin  equally  with  the  fat, 
the  delicate  and  the  robust,  are  exposed  to  the 
excruciating  torments  of  neuralgick  affections. 

The  season  of  the  year  is  also  equally  inca- 
pable of  regulating  its  occurrence. 


h  Recueil  de  la  Soc.  de  Med.  de  Paris,  Tome  iv.  p.  20a.  "  Cette  disser- 
tation de  Fortsmann  est  savante,  pleine  d'erudition,  et  merite  de  tenir  place 
parmi  les  bons  ecrits  sur  le  tic  douloureux  de  la  face.  On  y  trouve  des  ex- 
emples  de  jeunes  filles  de  neuf  et  de  vingt  ans  attaquees  du  tic  douloureux." 

«  Essay  on  Tic  douloureux,  by  Dr.  Jackson.     New-England  Journal,  1315. 


w  M 

Nor  is  Neuralgia  confined  to  one  part  of  the 
body.  Professor  Siebold,  of  Wurtzbourg,  enu- 
merates the  following  seats,  as  met  with  in 
authors : 

1.  In  one  single  part  of  the  face,  viz.  at  the 
inner  canthus  of  the  eye,  Fothergill ;  in  the 
orbita,  the  same ;  at  the  super  cilia  of  the  right 
eye,  Pujol ;  in  the  joint  of  the  jaws,  Selle, 
Pujol ;  in  the  maxilla  inferior,  at  the  passage 
of  the  nervus  infra-maxillaris,  (the  entrance  or 
exit?)  Lentin;  in  the  ossa  temporum,  Fother- 
gill ;  in  the  nervus  infra-orbitalis,  Albinus, 
Van  Wy,  and  many  others ;  in  the  ala  nasi, 
Vogler  and  Thouret ;  at  the  margin  of  the 
tongue,  Lentin. 

2.  In  one  half  of  the  face,  Fothergill  and 
others. 

3.  In  both  cheeks,  Pujol. 

4.  In  both  sides  of  the  maxilla  inferior,  at 
the  exit  of  the  nerve. 

5.  In  the  whole  head  and  face,  Lentin. 

6.  In  one  foot,  Lentin. 

Mr.  AbernethyV  remarkable  case  shews  its 
existence  in  the  ring  finger  of  the  left  hand,  ex- 
tending in  its  progress  up  the  nerves  of  the  arm. 
Dr.  Kelly l  witnessed  its  occurrence  in  the  fore 
finger  of  the  left  hand,  and  Mr.  Home771  has 

k  Surg.  Observ.  vol.  i.  p.  244. 

I  Dissertatio  Inauguralis  de  Neuralgia.     Edinb.  1810. 

m  Phil.  Trans,  for  1801. 


15   .  * 

met  with  it  in  the  thumb.  Dr.  Hosack  men- 
tions one  lady  whose  fore  finger  of  the  right 
hand,  and  another  whose  second  toe  of  the  left 
foot,  was  affected  by  Neuralgia.  "  In  the  Edin- 
burgh Medical  and  Surgical  Journal",  a  case 
is  recorded  by  Dr.  Verpinet,  as  occurring  in 
one  of  the  nerves  of  the  fore  arm,  the  conse- 
quence of  a  wound  with  a  knife'." 

The  face,  however,  is  most  subject  to  attacks 
of  Neuralgia,  which  has  been  satisfactorily  tra- 
ced to  a  morbid  affection  of  some  of  the  large 
nerves  which  render  that  portion  of  the  body  so 
susceptible  of  impressions.  The  portio  dura  of 
the  seventh  pair,  forming  the  pes  anserinus,  and 
the  nervus  communicans  faciei.  The  frontal 
nerve,  being  the  termination  of  the  ophthalmick 
branch  of  Willis,  or  first  branch  of  the  trige- 
mini;  the  ultimate  disposition  of  the  second 
branch  of  the  fifth  pair,  the  infra- orbit  ary  nerve; 
and  lastly,  the  mental  nerve,  the  third  branch 
of  that  important  trunk,  are  the  sources  of  pain 
and  suffering.  The  tongue,  the  tonsils,  the 
radial,  ulnar,  and  anterior  tibial  nerves,  have 
been  occasionally  affected  by  the  disease. 


n  Vol.  iii.  p.  14. 

o  American  Medical  and  Philosophical  Register,  vol.  iv.  No.  li, 


CH^LBmACTMRm 


The  character  of  this  affection,  as  given  by 
Sauvages,  under  the  name  of  trismus  dolorifi- 
cuSj  is  as  follows :  Est  difficultas  maxima  et 
valde  dolorifica  os  aperiendi  aut  movendi  cum 
uberi  ptyalismo,  pervigilio,  et  musculorum 
vicinorum  continua  et  convulsiva  agitatione. 
Dr.  Darwinp  has  criticised  this  location  and 
description,  objecting,  that  it  has  not  a  fixed 
spasm  like  the  locked  jaw.  But  certainly  the 
convulsion  of  the  face,  the  tetanick  (though 
temporary)  closure  of  the  lowrer  jawr,  and  the 
tremulous  agitation  of  the  jaw  and  lips,  are 
points  in  the  description  dwelt  upon  by  many 
writers.  Trismus  is  defined  by  Sauvages  to  be 
convulsio  vel  tonica  vel  clonica  maxillce  infe- 
rioris.  Therefore,  without  approbating  the 
ideas  of  the  great  French  nosologist,  Dr.  Dar- 
win might  well  have  spared  his  criticism,  and 
have  omitted  remarks  which  have  tended  to 
weaken  the  authority  of  his  illustrious  prede- 
cessor. 

The  following  character  may  be  less  exposed 
to  exception  than  many  which  I  have  seen: 
Neuralgia  is  marked  by  an  acute  pain  gene- 

p  Zoonomia,  CI.  I.  %  4.  12. 


17  4fe, 

rally  following  the  ramifications  of  some 
principal  nerve,  uncertain  in  its  time  of  at- 
tack, short  in  its  duration,  frequent  in  repe- 
tition, accompanied  by  a  convulsive  action  of 
the  neighbouring  muscles. 


BJESCJR1JPTIQJV* 


In  the  commencement  of  Neuralgia  faciei, 
the  correctness  of  the  old  appellation  is  per- 
ceptible ;  for  the  absence  of  swelling  or  any- 
other  external  mark  of  disease,  induces  the 
by-standers  to  reprove  the  patient,  for  his  ridi- 
culous and  disgusting  contortions  of  the  face. 
But  while  the  Chorea  Sancti  Viti  is  frequently 
unattended  by  any  other  distress^  than  what 
proceeds  from  the  unnatural  positions  of  the 
body  resulting  from  it,  Neuralgia  is  invariably 
calculated  to  draw  forth  the  deepest  commise- 
ration. Its  first  symptoms,  sometimes,  are  oc- 
casional irregular  twitchings  of  the  muscles  sup- 
plied by  the  diseased  nerve.  In  other  instances, 
its  strong;  resemblance  to  toothach  has  caused 
the  fruitless  sacrifice  of  many  teeth.  By  de- 
grees its  genuine  nature  developes  itself;  the 

3 


lb  18 

spasmodick  actions  increase  in  frequency  and 
acuteness,  and  a  distressing  and  embarrassing 
train  of  symptoms  is  noticed.     The  pain  is  very 
irregular,  and  fickle  as  to  its  hour  of  acces- 
sion.    The  patient's  rest  may  be  disturbed  night 
after  night,  as  well  as  his  comfort  destroyed 
during  the  day.     The  most  trifling  and  opposite 
occurrences  give  rise  to  the  spasms,  which  by 
their  severity  overcome  the  stoutest  resolution^ 
and  force  forth  loud  and  involuntary  screams  of 
anguish.     Washing  the  face,  moving  the  hand 
or  a  handkerchief  lightly  over  the  face7,  eat- 
ing, drinking,  speaking,  hawking  and  spittings 
sneezing,  coughing,  and  blowing  the  nose,  will 
either  of  them  in  a  moment  awaken  the  most 
poignant  and  acute  pain.     Even  touching  the 
face  with  a  finger,  slightly  rubbing  the  forehead^ 
putting  on  a  pair  of  spectacles,  or  even  only 
opening  the  mouth,  will  excite  a  return  of  the 
pains.    Taking  into  the  mouth  any  thing  hot, 
cold,  or  acid,  will  produce  the  effect,  perhaps 
with  aggravated  violence.     Combing  the  hair? 
shaving,  reading  aloud,  or  any  thing  that  gives 
the  slightest  motion  to  the  muscles  of  the  face, 
will  be  likely  to  occasion  in  the  part  a  throb- 
bing, which  seems  to  begin  like  the  vibration  of 
a  musical  cord,  extending  its  effects  to  the  cheeks, 
the  eye j  the  nose,  up  to  the  scalp  on  the  affect- 

q  Dr.  Gardner  Jones'  own  case.     Phil.  Med.  Museum,  new  series.   Vol.  I. 
No.  2, 


19  J 
ed  side  ;  or  from  the  corner  of  the  mouth  down- 
wards to  the  base  of  the  jaw.,  agitating  the  mus- 
cles of  the  chin  ;  after  continuing  a  few  seconds, 
sometimes  a  few  minutes,  and  in  aggravated 
cases  even  fifteen  or  twenty  minutes,  it   will 
cease,  and  the  part  which  had  been  affected  will 
enjoy   an  interval  of  perfect  ease.     When  the 
paroxysm  comes  on,  the  patient  s  whole  body  is 
convulsed  from  the  excess  of  agony  ;  the  eyes 
are  intensely  closed  ;  the  tears  trickle  down  the 
cheek;  the   mouth  is  distorted,  and,  with  the 
whole  cheek,  quivers  ;  the  body  unconsciously 
waves  backwards  and  forwards,  and  the  foot  of 
the  diseased  side  is  involuntarily  moved,  in  con- 
formity with  the  flexure  of  the  body.     Some- 
times, the  pain  seems  as  if  a  heated  knife,  or  a 
sharp  instrument  was  piercing  or  screwing  into 
the  flesh  ;  at  others,  as  if  red  hot  pincers  were 
tearing  or  twisting  it  from  the  bone.     The  in- 
terruption to  every  enjoyment,  and  even  every 
common  occupation  of  life,  as  admirably  describ- 
ed in  the  eloquent  letter  of  Dr.  Jones,  descrip- 
tive of  his   own  sufferings,  is  only  equalled  by 
the   degree  of  misery,  with  which    these   pa- 
roxysms are  attended.     The  wretchedness  of  a 
neuralgick  person  seems  to  approach  the  ex- 
treme of  human  misery ;  being  such  as  "  nei- 
ther words  can  describe,  nor  the   imagination 
easily  conceive." 


w  20 

The  preceding  delineation  is  applicable  to  a 
confirmed  case,  involving  most  of  the  facial 
nerves.  In  many  instances,  the  operations  of 
the  disease  are  more  confined,  and  give  rise  to 
a  deception  in  the  diagnosis.  The  first  case 
recorded  by  Sauvages,  was  mistaken  by  him  for 
Odontalgia,  and  treated  accordingly.  This  mis- 
take has  been  often  repeated,  as  the  obstinacy 
of  the  patient  points  to  the  gums,  or  a  carious 
tooth,  or  the  antrum  highmorianum ,  as  the  seat 
of  the  disease.  With  this  view  the  gum  has 
been  divided  in  various  directions,  many  teeth 
have  been  unnecessarily  extracted,  and  useless 
perforations  have  been  made  into  the  cavity  of 
the  upper  jaw. 

After  lasting  a  certain  time  in  one  portion  of 
the  face,  if  not  arrested,  every  neighbouring 
nerve  will  be  involved  in  the  malady.  In  Mr. 
Bosworth's  case  reported  by  Dr.  Darw7in,  the 
supra  and  infra-orbitar,  and  mental  nerves,  the 
branches  of  the  pes  anserinus,  and  also  the 
branches  of  the  superior  maxillary  nerve  pas- 
sing into  the  cheek  between  the  pterygoideus  in- 
ternus  muscle  and  the  upper  part  of  the  lower 
jaw,  were  successively  divided  before  relief 
could  be  obtained. 

Although  the  sufferings  of  the  patient  are  so 
great,  it  seldom  happens  that  the  constitution 
experiences  much  deterioration,  during  the  con- 
tinuance of  Neuralgia.     The  aged  most  gener- 


21 

ally  are  its  victims,  and  in  some  remarkable  in- 
stances, other  diseases  have  held  their  course  un- 
interrupted and  unmodified  by  this  formidable 
attendant.  In  Mr.  Pearson's  communication7" 
is  a  case,  however,  in  which  mortification  seized 
the  interior  of  the  cheek  surrounding  the  dis- 
eased nerve,  by  which  the  patient's  life  was 
destroved.  How  far  this  result  mav  have  been 
connected  with  the  previous  mercurial  treat- 
ment, it  is  impossible  to  hazard  an  opinion. 

Neuralgia  generally  attacks  but  one  side  of 
the  face  ;  instances  of  both  cheeks  being  involv- 
ed are  very  rare.  The  right  cheek  appears 
more  liable  to  its  occurrence  than  the  opposite. 
All  Dr.  Mott's  patients  were  afflicted  on  the 
right  side,  as  were  also  a  majority  of  the  cases 
recorded,  in  which  the  particular  cheek  is  spe- 
cified. 

r  Edinburgh  Medical  and  Surgical  Journal,  toL  3. 


21 


CAUSES* 


The  remote  causes  of  Neuralgia  are  very 
obscure.  In  a  plurality  of  cases,  no  predis- 
posing nor  exciting  causes  can  be  detected ;  in 
a  few,  some  local  injury  is  the  only  assignable 
cause.  Cold ;  violent  blows,  especially  on  the 
head  and  face ;  punctures,  as  in  bleeding ;  the 
partial  division  of  a  nerve ;  a  contusion,  as  from 
a  cannon  or  musket  ball ;  cicatrices ;  conges- 
tions ;  a  delicate  skin ;  chewing  of  acrid  sub- 
stances ;  excessive  talking ;  heavy  coughing ; 
long  continued  sneezing  or  blowing  of  the  nose  ; 
and  preceding  tooth ach,  are  enumerated  as 
having  given  rise  to  the  complaint.  Some  of 
these  are  evidently  mere  attendants,  and  in- 
competent to  its  production,  while  others  seem 
calculated  rather  to  excite  a  paroxysm  than 
the  disease.  Some  patients  have  been  cured 
by  close  attention  to  the  digestive  organs  ;  there- 
fore symptomatick  Neuralgia  may  be  consi- 
dered as  proceeding  from  and  depending  upon 
their  derangement. 

As  the  proximate  cause  of  disease,  should  be 
deemed  that  peculiar  condition  of  the  affected 
organ  which  gives  rise  to  the  characteristick  or 
attendant  symptoms,  we  shall  be  equally  at  a 


23 

loss  in  determining  the  proximate  cause  of 
Neuralgia. 

Dr.  Fothergill  is  inclined  to  believe  that  a 
cancerous  disposition  is  the  proximate  cause. 
"  My  subjects  were  for  the  most  part,  if  not  all., 
past  the  time  of  menstruation.  They  were 
generally  of  a  firm  and  somewhat  robust  fibre, 
generally  with  black  hair,  and  not  subject  to  any 
particular  diseases.  Most  of  them  had  borne 
children,  and  nothing  remarkable  had  occurred 
about  the  cessation  of  the  menses.  These  and 
other  appearances  induced  me  to  suspect  that 
the  cause  of  these  extreme  pains  in  the  face 
might  possibly  be  of  a  cancerous  nature ;  the 
method  of  cure,  and  other  circumstances  cor- 
roborated the   suspicion5." 

The  objections  of  Dr.  Haighton  are  opposed 
to  Dr.  Fothergill's  authority,  in  his  own  lan- 
guage. 

"  Out  of  several  patients,  whom  Dr.  Foth- 
ergill attended  with  this  complaint,  two  only 
had  schirrhous  indurations  of  the  breast,  or 
any  other  symptoms  of  Cancer. 

"  We  might  ask,  out  of  the  considerable  num- 
ber of  patients  labouring  under  Cancer,  how  few 
of  them  have  pains  in  the  face,  unless  the  Can- 
cer be  seated  in  that  part  ?  It  is  well  known 
that  local  complaints  of  various  kinds  may  at- 
tack the  same  patient,  without  having  the  least 
affinity  to  each  other. 

*  Med,  Observ.  and  Inq.  vol.  v.  p.  138, 


24 

iC  Cancer  manifests  itself  by  external  appear- 
ances,  as  induration,  ulcer,  &c.  This  disease 
produces  no  visible  change  in  the  organization 
of  parts,  how  long  soever  its  duration  may  have 
been. 

"  Cancer  is  seldom  very  painful  on  its  first 
appearance.  This  complaint  first  announces 
itself  by  its  acute  lancinating  pain. 

u  In  Cancer  the  pain  is  not  subject  to  perfect 
intermissions.  In  this  disease,  the  intermissions 
are  well  marked,  though  indefinite  in  their  du- 
ration. 

"  Cancer  is  always  aggravated  by  even  a 
simple  incision  on  the  part.  This  affection  has 
been  cured  by  a  simple  incision  in  a  proper 
place." 

Neither  sex  is  peculiarly  disposed  to  Neural- 
gia, while  the  habit  of  females  is  well  known 
to  be  obnoxious  to  cancerous  diseases.  The 
early  age  at  which  it  has  appeared  in  some 
females,  during  the  continuance  of  the  men- 
strual flux,  and  even  surviving  pregnancy,  is 
adverse  to  his  deductions  from  the  advanced 
life  of  his  patients. 

Analogy  in  medical  treatment,  is  a  dange- 
rous and  ill-founded  plea  for  identity  of  nature. 
The  powerful  effect  of  many  remedies  on  va- 
rious disorders  connected  with  the  nervous  sys- 
tem, on  this  ground,  would  argue  the  same 
proximate  cause  to  exist  in  all. 


who  J 


25 

a  Almost  all  the  authors  who  have  treated  of 
this  subject,  agree  in  assigning  arthritic  matter 
as  the  proximate  cause  of  the  disorder,  but  par- 
ticularly Dr.  Leidenfrost  Dr.  Degener  is  like- 
wise of  this  opinion,  having  observed  at  the 
affected  place,  a  tumour  similar  to  that  in  the 
joints  of  gouty  people.  Dr.  Siebold  saw,  in  a 
patient  suffering  the  most  violent  pains  at  the 
supercilia,  a  node  perfectly  like  that  of  arthritic 
limbs ;  and  Dr.  Ludwig  fairly  tells  us,  that  the 
patients  suffering  this  disorder  became  gouty 
soon  after.  The  disease  seems  to  have  an 
arthritic  origin  in  the  cases  related  by  Drs. 
Bohmer  and  Lavagan,  who  found  the  pain  dis- 
appear when  the  usual  arthritic  symptoms  re- 
turned *."  Dr.  Hosack  coincides  partially  with 
this  opinion,  thinking  that  in  one  case,  Mr.  Ap- 
thorpe's*  gout  was  intimately  connected  with 
Neuralgia.  Dr.  Rush,  in  his  chapter  on  gout3', 
expresses  his  opinion,  that  Neuralgia  is  of  gouty 
origin,  and  the  greater  frequency  of  gout  in  the 
female  sex,  according  to  his  ideas,  is  sufficient 
to  account  for  their  greater  exposure  to  Neu- 
ralgia. As  this  hypothesis  is  not  applicable 
to  every  case,  at  least  as  the  gouty  diathesis  can- 
not be  detected  in  many  instances  of  Neuralgia, 
it  may  be  safely  pronounced  inadequate  to  ex- 
plain the  mystery. 

t  Med.  &  Phys.  Journal,  No.  xxx. 

wAmer.  Med.  &  Philos.  Register,  vol.  iv.No.  11.  p.  299. 

y  Medical  Inquiries  and  Observations,  vol.  2. 


m 

Exanthemata  in  a  few  cases  have  had  some 
influence  on  the  disease,  but  the  irregularity  of 
that  influence  leaves  us  equally  uninformed  as  to 
the  probable  reason.  The  disappearance  of  a 
miliary  eruption  in  a  case  of  M.  Andre's,  re- 
moved the  pain,  which  returned  with  aggravated 
violence  on  the  recurrence  of  the  eruption. 
c:  Bonnard  and  Lavagan  relate  instances  of  her- 
petic eruptions  on  the  arm  having  preceded  the 
disorder  ;  and  the  German  translator  of  Dr. 
FothergilFs  works  saw  it  appear  after  a  retro- 
grade itch  :  the  pain  discontinued  when  the  itch 
broke  out  again,  but  as  soon  as  it  was  removed 
by  proper  remedies,  the  pain  immediately  re- 
turned :  and  the  disease  lasted  in  this  way  from 
the  nineteenth  year  of  a^e  to  the  twenty- se- 
venth."  * 

Menouret  and  Selle  assign  scropulpus  acri- 
mony as  the  cause  of  Neuralgia,  in  two  in- 
stances. 

Venereal  poison  has  been  considered  the  ori- 
gin of  this  disease  in  Mr.  Watson V  cases,  which 
were  cured  by  the  administration  of  mercu- 
rials. 

Ci  Dr.  Lentin  relates  a  case  in  which  a  puru- 
lent salivation  preceded  the  pain,  by  the  ap- 
pearance of  which  the  paroxysm  of  the  pain  be- 
came less  vehement  and  shorter  :  in  another 
case  the  pain  succeeded  a  running  of  the  ears  : 

r  Journal  de  Medicine    1793.  March. 


27 

and  Dr.  Thilemus  saw  a  patient  who  had  a  kind 
of  gonorrhea,  previously  to  the  pain,  which  be- 
gan to  run  again  as  soon  as  the  pain  had 
ceased/' 

After  this  detail  of  opinions  and  of  facts, 
from  which  nothing  conclusive  can  be  gathered, 
it  would  serve  no  useful  purpose  to  speculate 
any  further  on  the  proximate  cause  of  Neural- 
gia. The  relief  produced  by  an  operation  seems 
to  confine  the  morbid  action  to  the  nerve  af- 
fected, and  the  obscurity  of  nervous  pathology 
and  physiology  contributes  to  the  mystery  which 
envelopes  the  subject. 

The  effects  of  the  disease  on  the  nerve  are 
by  no  means  ascertained  with  precision.  In 
two  cases,  one  by  Dr.  Gilbert  of  Xew  Haven, 
examination  after  amputation  discovered  a 
condition  that  resembled  a  thickening  of  the 
nerve. 


28 


Bl*AGJVOSI§< 


On  referring  to  the  cases  of  Neuralgia,  sus- 
pected or  genuine,  which  have  been  submitted 
to  the  publick,  we  can  perceive  that  three  dis- 
eases have  been  confounded  with  it. 

Trismus  or  locked  jaw  can  hardly  ever  be 
mistaken  for  Neuralgia,  owing  to  the  involun- 
tarv  and  continued  contraction  of  the  levator 
muscles,  which  widely  differs  from  the  spasmo- 
dick  action,  violent  in  degree  though  short  in 
duration,  by  which  the  latter  is  characterised. 

The  other  diseases  are  odontalgia,  rheuma- 
tism of  the  jaw  and  face,  and  hemicrania. 

The  age  of  the  patient,  condition  of  the  teeth, 
and  direction,  nature,  and  course  of  the  pain, 
will  guide  us  in  the  diagnosis.  Although,  as 
before  observed,  young  persons  have  been 
afflicted  with  Neuralgia,  it  is  more  inclined  to 
fasten  itself  on  the  nerves  of  the  aged.  If  there 
be  any  carious  teeth,  as  they  may  operate  to 
a  certain  extent  on  the  disease,  their  extraction 
being  premised,  a  decided  opinion  can  be  form- 
ed. In  odontalgia,  the  pain  is  confined  to  the 
jaws,  extending,  by  nervous  sympathy  perhaps, 
through  the    alveolar   processes  of  both  ossa 


29  « 

maxillaria — it  cannot  be  moderated  by  pres- 
sure on  any  particular  spot — it  is  acute,  unre- 
mitting, and  often  unceasing,  until  the  offend- 
ing tooth  be  removed.  In  Neuralgia,  the  pain, 
though  often  referred  to  the  jaws,  is  seldom 
confined  to  the  neighbourhood  of  the  gums  ;  its 
direction  is  in  the  course  of  some  of  the  large 
nerves  connected  with  the  integuments  and 
muscles ;  it  can  often  be  moderated  by  firm 
pressure  on  some  principal  trunk,  and  its  re- 
currence by  paroxysms  will  satisfy  the  dis- 
cerning physician.  In  a  case  reported  by  Dre 
Jackson,  u  the  pain  had  the  most  important 
characteristics  of  Neuralgia.  It  was  uncertain 
as  to  the  time  of  its  attack,  sudden,  coming  by 
strokes,  or  darting,  and  excruciating  in  degree. 
It  was  mostly,  though  not  wholly,  confined  to 
the  portio  dura  of  the  seventh  pair  of  nerves. 
At  the  same  time  it  is  impossible  not  to  ascribe 
the  pain  to  the  tooth,  which  wras  so  long  a  time 
retained  under  the  gum."  The  absence  of  con- 
vulsion in  the  muscles  of  the  face  in  odontalgia, 
however,  may  be  considered  the  chief  diagnos- 
tick  symptom. 

More  difficulty  exists  in  deciding  between 
Neuralgia  and  rheumatism.  They  are  both 
acute  diseases;  both  may  produce  convulsive 
actions  of  the  mouth  and  cheeks ;  the  parox- 
ysms of  both  may  become  accumulated  in  fre- 
quency for  some  space  of  time,  leaving  an  inter- 


so 

st:  be 


val  of  entire  rest ;  both  may  be  relieved  by  pres- 
sure on  the  cheek ;   both  may  be  excited  by  the 
intervention  of  trivial  causes ;  and  both  may  be 
controlled  by  the  same  remedies.   Where,  then, 
shall  we  look  for  a  dia<rnostick  sign?  The  warmth 
of  a  bed  generally  heightens  the  acuteness  of 
rheumatism ;  Neuralgia  is  little  affected  in  de- 
gree of  violence,  by  the  accidental  circumstan- 
ces of  heat  or  cold.     The  rheumatick  diathesis  is 
usually  aggravated  by  a  change  from  a  dry  and 
clear  atmosphere  to  damp  and  rainy  weather ; 
while  the  other  disease,  though  sensibly  affected, 
does  not  obey  any  such  law  of  exacerbation  or 
diminution.      In    most    instances   of   obstinate 
rheumatism,  swelling  of  the  part  affected  is  a 
certain  consequence ;  but  in  Neuralgia  of  many 
years  duration,  no  alteration    of    the   integu- 
ments is  perceptible.     In  rheumatism,  a  patient 
is  sensible  of  a  tenderness  of  the  surface,  whe- 
ther he  be  suffering  from  a  paroxysm  of  pain, 
or  be  at  perfect  rest ;  while  in  Neuralgia  no 
such  tenderness   is   complained   of.       Should, 
however,  the  patient  consent  to  a  trial  of  the 
operation  for  Neuralgia,  he  will  be  satisfied  as 
to  the  nature  of  the  disease,  by  the  effect  which 
a  division  of  the  nerve  will  have  upon  the  pa- 
roxysms. 

The  periodical  nature  of  hemicrania ;  its  being 
confined  to  either  side  of  the  scalp  and  face ;  the 
absence  of  those  acute  spasms  noticed  in  Neu- 


31 

ralgia ;  its  recurrence  at  a  regular  hour  of  the 
day,  generally  at  noon ;  and  its  yielding  to  cin- 
chona and  alterative  medicines,  are  deemed  suf- 
ficient diagnostick  distinctions  between  hemi- 
crania  and  Neuralgia.  Dr.  Curry,  of  Guy's 
Hospital,  is  of  opinion,  that  hemicrania  is  only 
a  neuralgick  affection  of  the  nerves  supplying 
the  scalp  and  temporal  muscle. 


TRMA  TJWEJVT. 


Is  Neuralgia  a  disease  of  the  whole  system, 
or  is  it  to  be  considered  a  local  affection,  con- 
fined to  the  nerves  ?  According  as  this  ques- 
tion shall  be  determined,  will  be  our  indication. 
If  we  are  summoned  to  a  case  in  which  the  pa- 
tient complains  of  neuralgick  pain,  suddenly 
showing  itself  in  the  part ;  and  if  he  be  inclined 
to  gout  or  rheumatism,  we  may  safely  treat 
the  disease,  as  one  connected  with  the  arthritick 
or  rheumatick  diathesis.  At  all  events,  in  the 
employment  of  remedies,  as  palliative  or  cura- 
tive, the  distinction  will  be  serviceable  in  regu- 
lating the  class  of  medicines  which  should  be 
most  extensively  tried,  and  most  assiduously 
persevered  in.     Unfortunately  the  most  marked 


m 

cases  are  those  where  no  other  habit  of  body  is 
present,  and  where  the  progress  has  been  so 
slow  and  regular,  as  to  preclude  even  reasonable 
hopes  from  any  application  except  the  knife. 

The  tedious  and  innocent  advance  of  Neu- 
ralgia, has  afforded  ample  scope  for  medical 
experiment ;  and  of  the  great  variety  of  reme- 
dies put  in  requisition,  the  effect  has  been  va- 
rious in  the  hands  of  different  practitioners. 
The  malady  is  so  capricious,  that  at  one  period, 
nothing  but  the  most  powerful  impressions  ap- 
pear to  produce  any  alleviation ;  while  at  others, 
applications  the  most  simple  and  soothing  lull 
the  sufferer  to  rest. 

As  an  assistant  in  the  exhibition  of  pallia- 
tives, Dr.  Rush's  observation  to  Dr.  Jones,  is 
highly  important,  and  may  suggest  many  useful 
applications  in  this  and  analogous  diseases : 
'•  A  weak  sensation  of  a  pleasurable  nature 
may  predominate  over  a  painful  one."  The 
catalogue  furnished  by  that  venerable  martyr 
to  Neuralgia,  shows  the  assiduity  with  which 
he  embraced  every  possible  means  of  solace, 
and  answTers  as  a  useful  guide  and  beacon  to 
other  practitioners.  He  has  established  one 
fact,  that,  "  every  thing  in  this  wayward,  in- 
coercible  disease,  has  a  limited  season  of  utility, 
and  is  forthwith  either  inert  or  detrimental,  or 
of  trifling  avail." 


The  arrangement  of  articles  from  the  Materia 
Medica,  employed  to  cure  or  relieve  Neuralgia, 
is  that  adopted  by  M.  Alibert*,  in  his  able  and 
learned  work  on  Therapeuticks. 

1.  Of  the  substances  derived  from  the  vege- 
table and  mineral  kingdom  ivhtch  act  on  the 
tonick  poiver,  or  fibrillar  contractability  of  the 
stomach  and  intestines,  Cinchona  has  been  fruit- 
lessly employed.  It  has  been  exhibited  either 
in  the  form  of  powder,  or  the  compound  tinc- 
ture, or  conjoined  with  the  volatile  alkali,  as  re- 
commended by  Dr.  S.  Fothergill.  I  do  not  dis- 
cover that  Iron  has  been  relied  on,  or  faithfully 
tried.  The  extensive  agency  which  that  mi- 
neral has  exercised  in  the  prescriptions  of  mo- 
dern practitioners,  and  its  wonderful,  even  un- 
expected, beneficial  effects  on  some  occasions, 
would  seem  to  direct  the  attention  of  physicians 
to  its  employment.  The  contrary,  however, 
has  happened.  Its  prospect  of  affording  benefit 
is  quite  as  rational  as  that  of  many  other  reme- 
dies, which  have  been  administered  with  some 
success. 

2.  Catharticks,  constituting  the  class  of  me- 
dicines  ichich  act  on  the  myotility  or  muscular 
contractile  power  of  the  intestinal  canal,  have 
been  found  of  much  service. 

When  we  reflect  on  the  universal  connexion 
maintained  by  the  alimentary  system,  we  can 

a  Nouveaux  elemens  de  la  Therapentique,  et  de  matiere  medicale,  &c> 
Paris,  1814. 


34 

readily  conclude  that  powerful  impressions  made 
in  that  quarter,  would  affect  the  nerves  supplying 
every  part  of  the  body.  Dr.  Jones,  in  his  trials, 
entertained  a  high  opinion  of  a  moderate  purga- 
tive ;  and  was  sensible  of  the  beneficial  conse- 
quence of  its  operation  on  the  intestines,  even 
when  its  cathartick  effect  was  hardly  apparent, 

3.  Vegetable  and  mineral  substances  which 
act  on  the  stomach  and  intestines,  by  their  poi- 
sonous qualities. 

Of  the  efficacy  of  this  important  class  of 
remedies,  ample  experience  is  on  record,  in  the 
endeavours  to  cure  or  relieve  Neuralgia  by 
cicuta  or  conium  maculatum,  datura  stramo- 
nium, atropa  belladonna,  hyoscyamus,  and 
arsenick. 

Baron  Storck,  of  Vienna,  having  made  known 
his  experiments  on  the  anti-cancerous  virtues  of 
hemlock,  Dr.  Fothergiil  and  others,  relying  on 
the  reputation  of  the  Baron,  placed  their  confi- 
dence in  its  properties.  They  were  aware  that 
so  active  a  poison,  if  judiciously  exhibited,  must 
produce  decided  effects  on  the  animal  oecono- 
my  ;  and  accordingly,  Dr.  J.  Fothergiil  fully 
believed  that  Cicuta  would  cure  his  "  painful 
affection  of  the  face."  Dr.  Jackson's  remarks, 
and  experience  with  this  remedy,  are  very  use- 
ful ;  and  his  boldness  in  its  exhibition  is  an  evi- 
dence of  the  advantage  and  harmlessness,  with 
which  a  watchful  physician  may  administer  the 


85 

most  dangerous  medicines.  He  is  of  opinion, 
that  Dr.  Fothergill  could  not  be  mistaken  in  re- 
gard to  the  operation  of  hemlock ;  and  is  strength- 
ened in  that  idea,  by  the  opposite  results  report- 
ed by  two  able  colleagues  in  the  healing  arte 
The  various  quality  of  the  extract  is  assigned  as 
one  reason  for  this  difference.  The  imported 
Extractum  conii  maculati  is  generally  very  inert ; 
therefore  whenever  it  is  prescribed,  the  physi- 
cian should  be  well  satisfied  as  to  the  good  qua- 
lity of  the  article.  The  cautions  given  by  Dr* 
Fothergill  for  the  preparation  of  this  extract, 
are,  that  the  plant  should  have  acquired  its  full 
vigour,  and  should  be  rather  on  the  decline: 
"just  when  the  flowers  fade,  the  rudiments  of 
the  seeds  become  observable,  and  the  habit  of 
the  plant  becomes  yellow.  It  has  then  had  the 
full  benefit  of  the  summer  heat ;  and  the  plants 
that  grow  in  exposed  places,  will  generally  be 
found  more  virose  than  those  that  grow  in  the 
shade.  The  less  heat  it  undergoes  during  the 
preparation,  the  better." 

The  timidity  of  some  practitioners,  the  want 
of  confidence  of  others,  besides  the  indifference 
and  carelessness  of  a  third  set,  are  additional 
causes  of  the  failure  of  the  medicine. 

"  It  may  be  most  prudent  to  begin  with  a  sin= 
gle  grain  of  the  inspissated  juice,  but  we  may 
give  five  grains  for  the  second  or  third  dose ; 
and  afterwards  we  may  add  at  least  five  grains 


36 

to  every  dose,  until  we  produce  an  effect  on  the 
system."  u  When  given  in  a  full  dose,  it  oc- 
casions slight  nausea,  a  giddiness  more  or  less 
severe,  and  often  a  loss  of  muscular  power,  so 
that  the  patient  cannot  stand.  It  seldom  does 
good  unless  used  in  such  a  dose  as  to  produce 
these  effects  in  some  degree,  and  indeed  in  as 
great  a  degree  as  can  easily  be  borne."  "  I 
have  ventured  in  urgent  cases  to  repeat  the  dose 
every  half  hour.  I  believe  it  must  always  be 
abundantly  safe  to  repeat  them  once  in  two 
hours,  if  the  patient  and  attendants  are  careful 
and  watchful,  and  well  informed  in  regard  to 
the  effects*." 

Dr.  Fothergill  seldom  went  beyond  seventy 
grains  in  the  course  of  twenty- four  hours.  Dr„ 
Jones  ventured  to  one  hundred — but  Dr.  Jack- 
son administered  three,  hundred  grains  in  six 
hours.  "  I  conceived  that  if  the  system  could 
be  made  to  feel  the  effects  of  this  medicine  sud- 
denly and  powerfully,  there  would  be  a  chance 
of  effecting  a  real  cure ;  a  better  chance  than 
from  giving  a  much  larger  quantity  during  a  long 
space  of  time.  Accordingly,  after  having  ex- 
hibited the  medicine  for  about  a  fortnight,  and 
increased  the  dose  to  six  and  eight  pills  of  five 
grains  each,  and  having  ascertained  that  when- 
ever any  sensible  effect  was  produced,  it  took 
place  within  fifteen  or  twenty  minutes  after  the 

6  Dr.  Jackson  on  Tic  douloureux.    New-England  Journal. 


37 

dose  was  swallowed,  I  resolved  on  a  bold  trial 
of  this  medicine.     I  directed  eight  pills  to  be 
taken  as  soon  as  the  pain  should  come  on,  and 
that  the  same  should  be  repeated,  at  the  end  of 
twenty-five  or  thirty  minutes,  if  the  pain  should 
continue,  and  the  medicine  should  not  affect  the 
head  or  stomach.     At  this  time  the  paroxysms 
of  pain  had  become  inexpressibly  severe  and 
very  frequent     My   directions  were  carefully 
followed.     The  intervals  of  pain  were  such  as 
sometimes  to  prolong  the  intervals  between  the 
doses ;  but   in  the  course   of  six   hours,   sixty 
pills  were  taken,  making  three  hundred  grains, 
After  the  last  dose,  the  patient  was  quite  over- 
come by  the  medicine.     She  became  dizzy  and 
faint,  and  was  unable  even  to  sit  up.     She  laid 
upon  a  sofa  for  some  time,  in  a  state  of  intoxi- 
cation, but  without  suffering  any  very  unplea- 
sant effects  afterwards.     The  respite  from  pain 
and  from  susceptibility  of  pain,  was  more  per- 
fect and  longer  than  at  any  time  for  several 
weeks  before.     But  the  disease  was  not  con- 
quered ;  it  returned  the  next  day  with  consider- 
able severity.     1  had  directed  the  medicine  to 
be  repeated  as  soon  as  the  pain  should  return } 
which  was  done,  and   in  the  course  of  the  day 
forty-eight  pills,  two  hundred  and  forty  grains^ 
were  swallowed.     These  gave  entire  relief 5  and 
affected  the  head,  but  not  so  powerfully  as  on 
the  day  before.     The  disease  seemed  now  to  be 


vanquished.  This  was  in  November  1808. 
and  for  two  months  the  pain  was  not  felt,  ex- 
cept in  very  transient  twinges,  which  were  never- 
repeated  for  any  length  of  time.  About  the 
middle  of  January  following,  this  lady  walked 
out  on  an  extremely  cold  day,  and  the  disease 
returned  before  night,  with  very  considerable 
force.  The  hemlock  was  employed  again,  but 
in  smaller  doses  at  first.  In  three  days  the  dis- 
ease gave  way,  without  having  required  very 
large  doses  of  the  medicine.  Since  that  time  it 
has  never  recurred  ;  that  is,  during  more  than 
three  years." 

The  tincture  of  hemlock,  prepared  in  the 
same  proportions  as  the  tinctura  Digitalis  pur- 
pureae,  has  been  found  equally  efficacious  in 
Dr.  Jackson's  practice.  In  another  case  of 
Neuralgia,  he  began  with  thirty  drops  at  a 
dose,  "  to  be  frequently  repeated,  and  pre- 
sently increased,  if  relief  be  not  obtained. 
The  dose  was  gradually  increased  to  three 
hundred  drops.  It  never  gave  relief  except 
when  it  affected  her  head,  and  always  when 
it  did.  The  disease  yielded  in  two  or  three 
weeks  after  she  commenced  the  use  of  the 
hemlock,  and  since  that  time  it  has  not  re- 
turned." 

By  these  two  interesting  cases,  the  timidity 
and  unbelief  of  practitioners  should  be  dimi- 
nished ;   as  since  whatever  benefit  may  ulti- 


39 

mately  result,  the  precedents  afforded  by  a 
highly  respectable  physician,  will  justify  any 
trial  to  the  same  extent.  Perhaps,  from  the 
reasons  before  stated,  other  practitioners  have 
given  opposite  opinions  on  this  subject,  and 
have  been  inclined  to  believe,  that  the  gene- 
rality of  the  cases  reported  to  be  absolutely 
cured  by  hemlock,  were  actually  rheumaticke 
A  similar  belief  has  been  entertained  with  re- 
gard to  the  cures  said  to  have  been  effected  by 
Stramonium. 

Datura  stramonium  has  been  extensively 
employed  with  this  view  in  the  State  of  Con- 
necticut, especially  in  New-Haven,  and  its 
vicinity.  A  disease  sometimes  appears  in  young 
females  of  a  plethorick  and  rather  irritable  ha- 
bit, strongly  resembling  Neuralgia,  which  yields 
to  Stramonium,  and  may  have  given  rise  to  a 
belief  in  the  anti-neuralgick  virtue  of  that  vege- 
table'. A  case  of  this  I  have  never  seen,  and 
cannot  point  out  any  distinctive  marks  ;  I  know 
no  reason  why  it  may  not  be  genuine  Neuralgia, 
symptomatick  of  some  uterine  derangement. 
We  are  authorized,  however,  to  express  some 
doubts  as  to  its  efficacy,  in  general,  as  well  as 
of  Belladonna  and  Hyoscyamus.  According 
to  Dr.  Darwin,  "■  five  grains  of  the  powdered 
leaves  of  Atropa  belladonna,  are  recommended 
in  some  foreign  publications,  to   be   repeated 

c  MS,  Notes  on  Dr.  Mott'e  lectures. 


40 

once  in  two  days ;  and  are  said  to  be  success- 
ful*." 

"  After  a  few  days/'  says  Dr.  Jones,  "  arsenick 
produced  so  much  excitement  in  the  vascular 
system,  as  to  render  the  complaint  intolerable." 

Mr.  M'Kechnie's  case",  is  more  satisfactory 
and  consolatory.  "  On  the  1st  October,  1807, 
I  prescribed  the  following  mixture : 
1^  Soi.  min.  arsen. 
Aq.  pur.  a.  sj-  M. 
Of  this  the  patient  was  directed  to  take  fifteen 
drops  in  a  basin  of  gruel,  three  times  a  day, 
till  sensible  signs  of  the  operation  of  the  medi- 
cine should  be  observed.  For  a  few  days,  there 
was  no  alleviation  ;  but  as  the  dose  was  increas- 
ed, the  paroxysms  became  less  frequent,  and 
more  tolerable.  On  the  15th,  the  pains  were 
completely  gone ;  but  to  prevent  a  relapse,  I 
thought  proper  to  persist  in  using  the  mixture. 
On  the  17th,  violent  pain  seized  the  stomach; 
the  pulse  was  strong,  and  the  thirst  intense. — 
Blood  was  abstracted,  castor  oil  was  prescribed, 
and  copious  draughts  of  demulcent  drinks  Avere 
recommended.  The  medicine  was  also  inter- 
mitted ;  but  in  a  short  time  the  patient  was  so 
much  recovered,  that  it  was  resumed  in  small 
doses. 

"  14th  May,  1811.      The  painful  affection  of 
the  face,  has  never  returned  since  the  arsenical 

d  Zoonomia,  CI.  I.  2  4.  11. 

e  Med.  &  Phys.  Journal,  vol.  vii.  No.  xxvii.  p.  302. 


41 

solution  was  desisted  from  ;    and  the  general 
health  has  been  in  every  respect  good." 

In  those  instances  where  the  same  happy 
effects  are  not  experienced  from  the  use  of 
arsenick  alone,  its  combination  with  digitalis. 
as  recommended  by  Dr.  Currie,  u  by  bridling 
the  circulation/'  might  be  productive  of  mark- 
ed, and  perhaps  beneficial,  consequences.  The 
stimulating  property  of  arsenick  being  blunted 
by  its  adjunct,  it  might  direct  its  energy  towards 
the  nervous  S3^stem. 

4.  From  that  class  of  remedies  tohich  act 
particularly  on  the  vital  properties  of  the  large 
intestines,  much  assistance  has  been  derived. 
Enemata  were  strongly  recommended  to  Dr. 
Jones  by  Dr.  Rush.  He  employed  them  of 
different  degrees  of  pungency,  and  sometimes 
they  were  made  so  irritating  as  to  be  followed  by 
bloody,  mucous  discharges.  The  stimulus  of 
distention,  besides  the  irritating  quality  of  the 
injections,  at  first  was  beneficial,  but,  like  many 
other  useful  prescriptions,  they  were  soon  ranked 
among  the  "  inert  or  detrimental." 

5.  Of  venesection  and  leeches,  the  only  cura- 
tive measures  particularly  founded  on  the  vital 
properties  of  the  venous  circulation,  little  is 
recorded  in  relation  to  their  efficacy.  Their 
indication  depends  so  much  on  the  accessory- 
circumstances  of  each  individual  case,  that  no 

6 


42 

remarks  need  be  hazarded  as  to  their  employ* 
merit 

6.  Of  the  substances  derived  front  the  vege- 
table, animal,  and  mineral  kingdoms  which  act 
on  the  vital  properties  of  the  nervous  system, 
opium,  castor,  musk,  camphor,  assafcetida,  and 
zinc,  have  been  used  in  the  treatment  of  Neu- 
ralgia. 

The  usual  anodyne  property  of  opium 
has  been  much  relied  upon,  in  overcoming  the 
paroxysms  of  this  disease.  Astonishing  quan- 
tities have  been  administered ;  showing  the 
wonderful  ability  of  the  system  to  resist  power- 
ful medicines,  while  under  the  operation  of  an 
internal  excitement.  In  the  case  related  by 
Dr.  Hosack7,  which  was  cured  by  the  vol.  tine, 
of  Guaiac,  many  ounces  of  laudanum  were 
given ;  the  intensity  of  pain  prevented  much 
soporifick  effect,  and  it  failed  to  produce  a  cure, 
Opium  joined  to  nitre,  whose  sedative  quality 
through  the  medium  of  the  urinary  organs  is 
very  decided,  Dr.  Jones  found  more  efficacious 
than  when  administered  alone.  Dr.  Duncan g 
conducted  a  case  to  a  happy  termination  by  the 
6C  black  drop*/'  after  it  had  resisted  the  power 
of  opium  simply. 


/  Amer.  Med.  and  Phil.  Reg.  loc.  cit. 

g  Dublin  Med.  and  Phys.  Essays,  vol.  2. 

h  J^  Opii  purificati  uncias  quatuor;  pimenti  et  cinnamomi  utriusque 
drachmas  duas,  croci  et  cort.  aurant.  utriusque  drachmam  unam  ;  spiritus  vim 
libram  unam. 

Digere  per  dies  septem ;  tunc  cola,  et  adde  sacchari  chrystalizati  uncias 
duas  vcl  tres . 


43 

Annexed  to  Dr.  Kelly's  dissertation  is  a  de-? 
tailed  case  which  was  treated  by  opium,  united 
to  camphor,  cinchona,  and  aloetick  purges  after 
the  operation. 

The  remaining  articles  have  been  used  with- 
out success,  but  their  influence  in  other  dis- 
eases of  a  nervous  character  would  designate 
them  as  not  deficient  in  energy  for  this.  Their 
administration  is  certainly  justifiable  on  analo- 
gical grounds,  but  they  must  be  pushed  to  the 
extreme  which  the  constitution  will  admit. 

In  the  Medical  and  Physical  Journal,  No, 
183,  a  cure  is  said  to  have  been  effected  by  a 
mixture  of  equal  parts  of  zinc,  valerian,  hyos- 
cyamus. 

7.  The  next  class  is  composed  of  such  me- 
dicines ,  derived  from  the  vegetable ,  mineral \ 
and  animal  kingdoms,  as  act   on  the  vital 
properties  of  the  cutaneous  system,  considered 
as  an  exhaling  organ. 

The  analogy  traced  by  Dr.  Hosack  between 
Neuralgia  and  rheumatism,  has  induced  him  to 
repose  confidence  in  the  volatile  tincture  of 
guaiacum  officinale.  He  has  successfully  treat- 
ed one  severe  case  by  this  remedy,  and  its 
active  sudorifick  and  alterative  qualities  entitle 
it  to  high  consideration.  "  A  tea-spoonful  of  this 

1^..  Opii  uncias  quatuor  ;  succi  cydonii  mali,  librae  quatuor ;  digere  per 
tres  septimanas ;  tunc  adde  croci,  nucis  moschatce,  carjophiilorum  utriusque 
unciam;  iterum  digere  per  septimaaam,  cola  per  canulam,  et  evapora  liquo- 
rem  colatam  ad  syrupi  spissitudinem,— Kelly.  Dissertat.  Imug.  de  Neuralgia, 
Appendix . 


44 

medicine  was  given  every  two  hours  in  half  a 
a  glass  of  wine."  Its  use,  however,  is  evident- 
ly indicated  in  those  instances,  where  a  gouty  or 
rheumatick  diathesis  is  connected  with  Neu- 
ralgia. 

A  bag  of  common  salt  held  between  the 
cheek  and  the  gums,  by  the  copious  flow  of  sa- 
liva it  occasions,  has  produced  alleviation. 

Dr.  S.  Fothergill  strongly  recommends  the 
aqua  ammonise  causticae  as  a  powerful  remedy  ; 
and  Dr.  Jackson  in  one  case  confirms  the  strong 
bias  in  its  favour  expressed  by  Dr.  F. 

8.  Remedies  particularly  applied  to  the  vi- 
tal properties  of  the  nervous  system,  consider- 
ed as  an  organ  of  sensation. 

Blisters,  sinapisms,  and  issues,  all  acting  with 
a  two-fold  intention,  as  irritants  and  as  drains, 
have  been  found  of  little  service  in  Neuralgia. 
Issues  promise  more  benefit  than  the  other  ap- 
plications. Dr.  Jones  made  trial  of  several  at 
the  same  time,  which,  though  not  fulfilling  the 
expectations  he  had  formed,  were  for  a  season 
of  some  benefit. 

Electricity,  both  in  form  of  sparks  and  of 
the  aura,  has  been  much  resorted  to.  Dr. 
Haighton's  experience  is  rather  against  its  utili- 
ty, and  Drs.  Rush  and  Jones  consider  it  a  very 
feeble  resource. 

The  salutary  influence  of  the  magnet  on  the 
nervous  system,  is  more  acknowledged.    Messrs. 


45 

Thouret  and  Andry,  and  the  Abbe  Lenoble^ 
have  made  extensive  experiments  on  this  sub- 
ject. They  have  described  cures  of  odontalgia, 
head  ach,  and  tic  douloureux.,  by  means  of  the 
artificial  magnet.  In  a  case  of  severe  pains  in 
the  upper  jaw,  that  baffled  every  attempt  at 
relief  by  other  means,  M.  Lenoble  contrived  a 
magnetick  coronet,  collar,  cross  for  the  breast, 
and  two  plates  for  the  legs,  which  removed 
ever j  symptom  of  the  complaint.  Professor 
Sparmann  employed  the  magnet  in  two  cases  of 
dolor  faciei,  and  the  relief  it  afforded  was 
very  striking,  though  a  complete  cure  was  not 
effected^.  On  this  head,  Dr.  Jones  is  explicit 
and  instructive.  "  For  a  considerable  time  it 
lulled  the  pain  like  a  charm,  and  its  operation 
was  so  prompt  and  effectual  in  repelling,  at 
least,  minor  attacks,  that  I  found  in  it  a  valua- 
ble auxiliary.  As  often  as  I  was  roused  from 
sleep  by  darting  pains  or  twinges,  I  applied  it 
with  such  success,  that  at  length  I  slept  with  it 
in  my  mouth,  and  in  this  way,  passed  the  night 
comfortably  ;  but  after  a  certain  time,  it  seemed 
gradually  to  lose  its  efficacy  as  a  remedy,  though 
its  magnetic  virtue  remained  nearly  the  same ; 
or  it  may  be,  the  pain  becoming  more  severe, 
greater  power  in  the  remedy  was  required  to 
produce  the  same  effect ;  and  yet  on  procuring 
a  larger  magnet,  which  probably  concentrated 

k  Alibert?  Nouveaux  Siemens  de  la  Therapeutique,  &c  Tome  II.  p.  450, 


46 

more  magnetism  within  a  given  compass,  this 
proved  too  powerful  for  my  purpose.  The  part 
affected  could  not  bear  the  stronger  at  all,  and 
the  weaker  served  as  the  pain  was  going  off,  to 
check  it  the  more  suddenly."  Some  attention, 
therefore,  is  required  in  regulating  the  size  of  the 
magnet,  and  had  the  Doctor  with  more  assidui- 
ty graduated  this  instrument  to  the  degree  and 
severity  of  his  sufferings,  more  assistance  might 
have  been  received. 

Analogous  to  this  plan  of  treatment,  is  that 
recommended  by  Heurteloup',  whose  curious  and 
successful  device  was  the  wearing  of  an  iron 
mask  on  the  face. 

Galvanism,  which  seems  to  be  a  medium  be- 
tween electricity  and  magnetism, in  theenergetick 
effects  it  displays  analagous  to  those  of  the  first, 
while  its  silent  and  unseen  agency  resembles  the 
latter,  might  be  supposed  of  more  utility  than 
either';  but  experience  does  not  warrant  the 
conclusion. 

Cold,  hot,  and  tepid  bathing,  fomentations, 
and  a  heated  atmosphere  have  been  tried,  and 
with  various  success.  The  general  rule  concerning 
the  employment  of  cold  water  in  persons  of  ner- 
vous habits,  is  applicable  to  Neuralgia ;  where  it 
produces  an  increase  of  suffering,  its  use  must  be 
suspended.  Pediluvium  in  warm  water,  from 
its  soothing  and  grateful  influence  on  the  sys- 

l  Journ.  de  Med.  1811. 


47 

tern,  is  strongly  recommended  as  an  auxiliary ; 
and  it  may  be  assisted  by  wrapping  the  head  in 
cloths  wrung  out  of  warm  water,  or  warm 
brandy  and  water.  Bathing  has  been  too  little 
watched  for  any  decided  report  concerning  its 
utility.  The  preservation  of  an  uniformly  high 
temperature  in  his  chamber,  Dr.  Jones  found 
rather  to  increase  his  sensibility,  than  to  lull  the 
pain.  After  a  few  days,  the  slightest  breath  of 
cooler  air  would  renew  his  agony  with  increased 
violence. 

Frictions  and  embrocations,  camphorated  and 
combined  with  opium,  maintain  their  standing 
for  a  limited  period,  and  then  must  be  abandon- 
ed as  useless. 

Incisions  in  the  gums,  and  neighbourhood 
of  the  part  immediately  affected,  have  been  pro- 
ductive of  some  benefit;  but  so  short  lived  was 
the  relief,  as  hardly  to  give  them  any  character 
as  a  resource. 

Ice  held  in  the  mouth  or  on  the  diseased 
nerve,  by  benumbing  the  part,  has  prevented 
the  immediate  return  of  the  paroxysms. 

Tar  has  been  successfully  employed  in  one 
case  communicated  by  Mr.  Colville*,  after 
many  other  expedients  had  failed.  It  was 
adopted  in  consequence  of  the  resemblance  of 
the  disease  to  rheumatism.  If  I  may  venture 
an   opinion,   although  the   symptoms   detailed 

l  Edinb.  Med.  and  Surg.  Journal,  vol.  x.  No.  39, 


48 

correspond  with  those  of  Neuralgia,  the  disease 
must  have  been  on  the  decline,  or  must  have 
been  intimately  connected  with  rheumatism  : 
otherwise,  an  application  so  simple  and  inert 
would  hardly  have  manifested  any  decided  ope- 
ration on  an  affection  so  obstinate,  and  deeply 
rooted,  as  confirmed  Neuralgia. 

9.  Of  the  substances  which  act  on  the  cuta- 
neous system,  considered  as  an  absorbing  or- 
gan ,  mercury  has  been  resorted  to  for  the  cure 
of  this  disease.  Mr.  Pearson,  in  his  paper  be- 
fore mentioned,  describes  the  condition  of  seve- 
ral patients  whose  affliction  was  removed  by 
salivation.  Mr.  Watson7"  also  treated  the  disease 
in  the  same  manner.  Hufeland",  in  Ger- 
many, has  published  the  cure  obtained  by 
the  extract  of  hyoscyamus  niger  combined 
with  calomel.  Dr.  Jones  placed  some  con- 
fidence in  the  apparently  universal  agency 
of  this  mineral.  After  salivation  had  been  gra- 
dually produced  by  the  corrosive  muriate,  and 
moderately  maintained  for  a  few  days,  his  sys- 
tem became  so  irritable,  that  the  attacks  of  his 
dire  enemy  were  more  frequent  and  excruciating 
than  before. 

m  Journal  de  Medicine,  1793.     March. 
n  Journ.  de  Med.  vol.  xvi. 


49 


SUMGICAL    TME*ATJWEJVT. 


The  system  of  treatment  described  in  the 
foregoing  pages,  in  conformity  with  the  twofold 
plan  of  managing  hydrocele,  may  be  denomi- 
nated the  palliative.  The  remaining  section 
of  this  dissertation  will  be  devoted  to  the  radical 
or  surgical  treatment. 

The  history  of  the  operation  is  coeval  with 
the  first  lucid  description  of  Neuralgia.  In  an 
instance  related  by  Sauvages,  the  celebrated 
surgeon  Mareschal  divided  the  nerve ;  the  pa- 
tient, who  had  suffered  excessively  from  the 
disease,  slept  well  that  night ;  but  within  a  few 
days  the  disease  returned.  "  Tandem  post 
biennium  Audraeas  ope  lapidis  caustici  ad  nasi 
latus  inusti,  aquoe  mercurialis  supra  escharam 
affusse,  incisionis  ad  os  productee  post  duodecim 
dies,  quibus  hee  operationes  institutes  sunt,  sta- 
timam  sublevit,  quae  denique  omnino  sanata 
fuit ;  cum  chirurgus  initio  denudatum  stylo  at- 
tingebat,  paroxysmum  trismi  pro  lubitu  excita- 
bat,  cicatrice  obducta,  &gra  sana  vixit0" 
Andre  employed  caustick  as  his  great  curative 

o  Nosol.  Method,  vol.  iii.  p.  19= 


50 

indication,  and  his  practice  prevails  in  France 
at  the  present  period.  In  an  aggravated  case 
of  Dr.  Haighton's,  reasoning  on  the  apparent 
pathology  of  the  disease,  he  was  convinced  that 
a  division  of  the  nerve  would  be  effectual  in  its 
consequences ;  nor  was  he  deceived.  The  tes- 
timony of  many  surgeons  is  united  on  this 
point.  Dr.  Haightonp,  besides  his  own  expe- 
rience, quotes,  from  Sabatier's  anatomical  trea- 
tise, one  instance  from  De  Haen's  Ratio  Me- 
dendi ;  another  by  Mr.  Ritch,  a  Polish  surgeon 
of  high  respectability ;  and  a  third  in  Paris,  in 
which  the  success  was  only  temporary.  M. 
Louis9  practised  this  operation  with  success 
on  a  prior  of  Premontres.  In  addition  to 
Dr.  Haighton's  authority,  many  excellent  sur- 
geons admit,  that  where  the  nerve  can  be 
effectually  divided,  a  perfect  suspension  of 
misery  will  be  attained,  at  least,  until  the 
nervous  re-union  be  effected. 

The  most  strenuous  advocate  for  the  opera- 
tion, in  this  country,  is  Professor  Mott.  His 
success  has  been  so  unequivocal,  and  his  op- 
portunities of  witnessing  the  disease  so  compa- 
ratively numerous,  that  his  unqualified  opinion 
in  all  cases  of  Neuralgia,  is  '  divide  the  nerve ; 
then,  if  necessary,  employ  the  other  remedies 
to  destroy  or  diminish  the  susceptibility  to  re- 

p  Med.  Records  and  Researches. 
q  Gazette  Salutaire,  No.  36.     1766. 


51 

turn,  which  will  be  accomplished  most  certainly 
by  hemlock  and  other  narcoticks.  Dr.  Mott  has 
operated  on  five  patients.  He  has  divided  dif- 
ferent nerves  on  Dr.  Jones'  face  eleven  times,  but 
the  disease  seems  so  rooted  in  the  old  gentleman's 
constitution,  as  to  require  frequent  repetition  of 
the  operation.  He  has  become  so  accustomed 
to  it,  that  whenever  the  inveterate  tormentor 
developes  itself,  he  sends  for  his  surgeon  with- 
out delay,  knowing,  that  from  his  hands  he 
shall  receive  relief.  Mr.  George  G.  Graham, 
practitioner  in  Orange  County,  while  a  student 
of  medicine,  divided  the  infra-orbitar  nerve 
with  perfect  success ;  and  Dr.  Post,  associated 
with  Dr.  Mott,  operated  lately  on  a  gentleman, 
whose  left  cheek  was  diseased,  and  he  instantly 
arrested  the  spasms. 

The  degree  of  certainty  promised  by  the 
operation,  as  resulting  from  the  physiology  of 
nervous  re-union,  becomes  an  interesting  ques- 
tion. Dr.  Haighton's  masterly  and  conclusive 
experiments  on  the  re-union  of  divided  nerves, 
have  completely  established  that  point :  and  it 
is  a  settled  dogma  in  physiology,  that  by  the 
growth  of  fresh  matter,  or  by  the  approxima- 
tion of  the  divided  ends,  the  functions  of  a  nerve 
are  restored.  Mr.  Abernethy,  however,  arguing 
from  the  renewed  sensibility  and  mobility  of  the 
ring  finger  on  which  he  operated,  thought  that 
the  anastomosing  branches   had   become  en- 


52 

larged,  and,  officiating  in  lieu  of  the  original 
trunk,  rendered  a  complete  cure  impracticable. 
Had  that  learned  surgeon  removed  a  portion  of 
the  trunk  of  the  ulnar  nerve,  and  then  been 
baffled  in  his  anticipated  cure,  his  apprehension 
would  be  well  founded.  There  is  some  differ- 
ence between  the  effects  of  a  divided  trunk  and 
of  its  branches.  Nervous  influence  can  readily 
be  re-communicated  by  the  preservation  of  the 
former,  should  the  latter  be  effectually  operated 
upon.  Moreover,  as  the  nerve  of  the  opposite 
side  of  the  finger  was  derived  from  the  radial 
nerve,  the  difficulty  of  solving  the  mystery  is 
diminished. 

In  opposition  to  the  utility  of  operating,  the 
uncertainty  of  immediate  relief  from  a  division 
of  the  nerve  has  been  particularly  urged.  For5 
say  they,  the  re-union  is  so  speedy  and  so  cer- 
tain, that  nature  will  commence  her  counter- 
vailing process  before  the  desired  object  is  com- 
pletely attained  ;  thus  tantalizing  the  patient 
still  more,  and  adding  unnecessarily  to  his  suf- 
ferings. The  author  of  a  thesis"  supported  be- 
fore the  Faculty  of  Medicine  of  Paris,  expresses 
his  doubts  of  the  success  of  the  operation ;  he 
pretends  that  it  was  repeated  five  times  on  one 
patient,  and  asserts  that  he  finally  owed  his 
cure  to  the  warm  baths  of  Plombieres. 

r  Utrum  in  pertinacibus  capitis  &  faciei  doloribus  aliquid  prodesse  possif, 
sectio  ranjorum  nervi  quinti  pari? ,?  proponebat  Veillart,  1768,  conclusio 
negativa. 


53 

In  the  same  dissertation  are  the  histories  ot 
two  other  patients,  on  whom  a  Parisian  surgeon 
practised  without  success  the  division,  and  af- 
terwards the  cautery  on  the  supra  and  infra- 
orbital* nerves,  the  malar  branches  of  the 
portio  dura,  and  the  mental  nerve'.  The 
preceding  remarks  on  the  success  of  the  ope- 
ration are  a  full   reply  to  such  objections. 

Wherever  a  considerable  portion  of  the  nerve 
can  be  abstracted,  a  greater  duration  will  as- 
suredly be  given  to  the  cure.  This  cannot  be 
attempted  on  many  of  the  nerves  of  the  face; 
because  the  ramification  is  so  immediate  and 
extensive,  as  to  preclude  a  successful  endeavour 
to  remove  much  of  the  frontal,  infra- orbital,  or 
mental  nerves.  The  branches  of  the  pes  anse- 
rinus  are  intimately  connected  with  the  parotid 
gland  and  duct ;  also  by  some  very  beautiful  and 
extraordinary  anastomoses  with  the  other  facial 
nerves,  so  that  a  similar  hinderance  occurs  here. 
The  only  nerve  about  the  head  which  affords 
the  slightest  chance  for  effectual  and  final  divi- 
sion is  the  portio  dura,  in  its  passage  between 
the  stylo-mastoid  hole^  and  the  angle  of  the 
lower  jaw.  When  the  disease  is  in  any  other 
part  of  the  system,  if  half  an  inch  of  the  princi- 
pal trunk  supplying  the  affected  spot  could  be 
removed,  there  would  be  little  dread  of  its  re- 
turn.    A  repetition  of  incisions  through  a  nerve, 

s  Richerand  Nosographie  Chirurgicale,  T.  II.  p.  204. 


54 

by  insulating  several  portions,  would  be  another 
means  of  protracting  a  renewal  of  the  disease ; 
and  in  the  sub-orbitar  nerve,  this  has  been  done 
by  Doctor  Mott,  when  operating  on  Doctor 
Jones".  This  improvement,  I  believe,  is  attri- 
butable to  Doctor  Mott,  and  its  application  must 
be  productive  of  decided  and  happy  conse- 
quences. 

It  is  a  curious  circumstance  connected  with 
the  operation,  that  although  the  nerve  shall  be 
completely  divided,  from  some  cause,  the  chain 
of  morbid  actions  will  not  be  interrupted  for 
several,  perhaps  twelve  or  fourteen,  days.  This 
has  induced  some  to  pronounce  hastily,  that  the 
operation  has  failed.  Any  attempt  satisfactori- 
ly to  explain  this  occurrence,  I  think  would  be 
fruitless. 


Operation  on  the  infra-orbitar  nerve. 

The  participation  of  this  nerve  in  Neuralgia^ 
may  be  detected  by  the  course  of  the  pain  up 
the  side  of  the  nose.,  sometimes  following  an 
arched  direction  between  the  eyebrow  and  up- 
per lid,  or  in  either  the  brow  or  lid,  and  extend- 
ing along  the  zygomatick  arch :  or  it  may  be 
confined  to  the  muscles  passing  between  the  os 

r  Medical  R-epository,  {new  series,)  Vol.  II.  No.  2. 


55 

malae  and  the  angle  of  the  mouth,  involving  the 
buccinator  and  masseter.  Pressure  may  be  ap- 
plied to  the  infra- orbitar  foramen,  during  which 
the  pain  will  be  arrested,  provided  the  disease 
depends  on  that  nerve.  A  tremulous  motion  of 
the  upper  lip  on  one  side,  most  commonly  at- 
tends this  variety  of  Neuralgia. 

To  Doctor  Haighton  we  are  indebted  for  an 
excellent  view  of  this  nerve,  and  a  delineation 
of  the  point  for  division.  "  He  measured  the 
space  between  the  inferior  edge  of  the  orbit  and 
the  superior  edge  of  the  foramen  in  thirty  skulls, 
and  found  the  distance  in  sixteen  skulls  |  of 
an  inch,  which  he  considers  the  medium  distance 
from  the  upper  part  of  the  foramen ;  and  if  we 
allow  i  of  an  inch  for  the  breadth  of  the  fo- 
ramen, and  i  below  its  inferior  part,  half  an 
inch  from  the  lower  edge  of  the  orbit  will  be  a 
proper  place  for  performing  the  operation, 
Having  endeavoured  to  establish  a  rule  for  de- 
termining its  distance  from  the  orbit,  it  may  be 
proper  to  ascertain  its  situation  with  respect  to 
a  line  drawn  from  the  inferior  part  of  the  in- 
ternal angular  process  of  the  osfrontis,  ob- 
liquely across  the  orbit,  to  the  centre  of  the  os 
Tnalce.  The  measurement  of  this  line  in  thirty 
skulls,  did  not  vary  more  than  i  of  an  inch, 
and  it  was  found  that  a  line  drawn  downward 
perpendicular  to  this  oblique  line,  at  the  distance 
of  I  of  an  inch  from  the  internal  angle  of  the 


56 

eye,  passed  across  the  orifice  of  the  sub-orbitar 
foramen." 

This  point  being  settled.  Dr.  Haighton's  di- 
rection for  operating,  is  "  to  make  an  incision  of 
|  of  an  inch  in  length,  carried  obliquely  down- 
wards, (on  account  of  the  oblique  course  which 
many  of  these  nerves  take,  in  their  passage  from 
the  foramen  to  the  ala  nasi,)  the  centre  of  which 
must  correspond  with  the  foramen,  only  \  of 
an  inch  below  it.  The  incision  must  be  made 
down  to  the  bone,  otherwise  we  cannot  be  cer- 
tain of  dividing  the  nerves,  as  they  are  situated 
very  deep." 

The  deformity  produced  by  a  large  cicatrix, 
in  this  method  of  operating,  exposes  it  to  objec- 
tion. Professors  Post  and  Mott  have  employed 
the  following  mode  with  the  happiest  success, 
and  perfect  facility. 

The  only  instrument  required  is  a  sharp- 
pointed  bistoury  or  phymosis  knife,  either  in 
a  stiff  handle,  or  well  secured. 

Having  ascertained  the  situation  of  the  infra- 
orbitary  foramen,  by  Dr.  Haighton's  rule,  and 
also  by  the  depression  which  can  be  distinguish- 
ed in  most  subjects,  let  the  nose  be  held  aside 
by  the  assistant  who  secures  the  patient's  head. 
Introduce  the  bistoury  about  midway  between 
the  nose  and  the  nasal  margin  of  the  foramen  ; 
carry  it  down  to  the  bone,  and  pass  the  point 
dose  to  the  bone,  in  order  to  get  it  under  the 


ot 

nerve.  The  point  must  then  be  elevated  a  lit- 
tle, though  it  must  not  pass  through  the  skin 
from  beneath ;  by  a  little  rubbing  motion  with 
one  finger  upon  the  point  of  the  knife,  at  the 
same  time  cutting  gently  with  the  knife,  the 
nerve  will  be  divided. 

As  a  considerable  branch  of  the  internal 
maxillary  artery  accompanies  the  infra-or- 
bital nerve,  its  division  will  be  shown  by  a 
copious  arterial  haemorrhage ;  and  a  pecu- 
liar acute  pain  accompanies  the  section  of  the 
nerve,  in  addition  to  the  difference,  percepti- 
ble to  the  operator,  between  cutting  a  nerve, 
and  any  other  soft  solid.  The  upper  lip  must 
now  be  examined  by  touch.  If  the  patient  ac- 
knowledge a  destruction  of  sensibility,  the  sur- 
geon may  withdraw  his  bistoury:  otherwise,  the 
cutting  must  be  repeated,  until  from  numbness, 
he  is  satisfied  that  the  nerve  is  divided.  By 
asking  the  question  previously  to  withdrawing 
the  knife,  the  patient  has  no  reason  to  conceive 
that  any  disappointment  attended  the  first  at- 
tempt, and  the  repetition  of  incisions  he  may 
suppose  to  belong  regularly  to  the  operation. 
Being  certain  that  the  nerve  is  thoroughly  di- 
vided  at  the  first  point  of  section,  make  two  or 
three  incisions  through  it  lower  down  ;  and  thus 
endeavour,  as  Dr.  Jones  expresses  it,  to  ''  insu- 
late a  portion  of  it,  (included  as  it  were  in  a  pa- 
renthesis,) with  respect  to  the  common  senso- 

8 


58 

rium."  Since  the  infra- orbitary  nerve  as  it 
leaves  the  foramen  expands  immediately  like  a 
fan,  and  distributes  its  branches  to  the  sur- 
rounding parts,  the  incisions  last  mentioned 
may  be  extensive,  retaining  the  knife  still 
underneath  the  skin.  The  knife  is  then  to  be 
withdrawn  through  the  first  opening,  and  the 
lips  of  this  diminutive  external  wound  can  be 
drawn  together,  and  secured  by  adhesive  plas- 
ter. 

The  only  obstacle  to  a  free  section  to- 
wards the  nose,  is  the  facial  vein,  which,  be- 
ginning at  the  inner  angle  of  the  eye,  holds  a 
diagonal  course  towards  the  angle  of  the  jaw. 
A  wound  of  this,  however,  will  not  be  attended 
with  any  serious  consequences  ;  it  will  only  add 
to  the  ecchymosis  already  arising  from  the  ar- 
tery, and  can  be  compressed  by  a  slight  force 
applied  to  the  spot.  The  suffusion  of  blood 
will  be  removed  by  absorption  in  a  few  days, 
and  its  removal  may  be  aided  by  any  mode- 
rately stimulating  lotion. 

The  great  advantage  of  this  method  over 
Dr.  Haighton's,  will  be  apparent  from  the  im- 
possibility of  any  large  cicatrix  being  the  con- 
sequence. 


59 


Operation  on  the  Frontal  nerve. 

This  final  distribution  of  a  highly  useful  and 
important  branch  of  the  trigemini,  after  it  has 
entered  the  orbit  through  the  foramen  lacerum, 
appears  to  cling  to  the  roof  of  the  orbit,  passing 
between  the  bone  and  the  periosteum r,  of  course 
above  the  levator  muscle  of  the  upper  eyelid. 
It  leaves  the  orbit  through  the  supra-orbitar 
foramen,  which  in  many  skulls  is  only  a  notch, 
closed  below  by  a  ligament.  The  situation  of 
this  hole  or  notch  may  be  ascertained,  with 
tolerable  precision,  by  finding  the  sub-orbitar 
foramen ;  as  it  is  about  |  of  an  inch  within  a  per- 
pendicular line  drawn  from  the  latter,  and  con- 
tinued up  the  forehead. 

Pass  a  bistoury  or  knife  about  §  of  an  inch 
within  the  orbit,  immediately  beneath  the  su- 
perciliary ridge  of  the  os  frontis,  and  divide  the 
nerve  outwardly.  A  numbness  must  be  felt  on 
the  forehead  and  eyebrow,  and  down  the  nose/ 
before  the  knife  is  withdrawn.  The  connexion 
between  the  nerve  and  the  bone,  is  sufficient  to 
impress  the  necessity  of  keeping  the  point  of 
the  bistoury  as  close  as  possible  to  the  bone, 

r  Meckel.    Tractatus  Anatomico-physiologicus    de   quinto  pare  nervorum 
cerebri.     Sec.  xxxix. 


60 

and  the  dense  periosteum  affords  additional  re- 
sistance, while  dividing  the  nerve.  The  ophthal- 
mick  artery  will  bleed  profusely  for  a  few  mi- 
nutes, and  when  its  flow  outwardly  is  repressed , 
it  will  produce  so  much  ecchymosis  as  to 
blacken  the  eye  to  a  considerable  extent. 


Operation  on  the  Mental  nerve. 

The  foramen  through  which  emerges  the  in- 
ferior-maxillary branch  of  the  fifth  pair,  is  situ- 
ated generally  about  midway  between  the  al- 
veolar processes  of  the  jaw  and  its  base,  in  a 
line  between  the  cuspidatus  and  anterior  bicus- 
pid teeth.  The  nerve  may  be  divided  by  turn- 
ing down  the  lip,  and  introducing  the  bistoury 
about  the  first  bicuspid  tooth,  with  the  back 
towards  the  angle  of  the  jaw.  Keep  the  knife 
close  to  the  bone,  and  by  following  the  excava- 
tion of  the  jaw,  the  nerve  will  be  divided  by  a 
cutting  motion  rather  from  the  bone. 

In  the  aged  edentulous  subject,  from  the  ab- 
sorption of  the  alveolar  processes,  no  reference 
can  be  made  to  the  teeth,  in  finding  the  mental 
foramen.  It  is  situated  generally  in  the  same 
line  with  the  supra-orbitary  hole,  and  conse- 
quently can  easily  be  discovered. 


60 


Operation  on  the  Portia  Dura. 

A  mere  description  of  the  complicated  and 
extensive  distribution  of  this  nerve,  will  be  suffi- 
cient to  justify  a  doubt  of  any  operation  being 
so  devoid  of  danger,  or  troublesome  conse- 
quences, as  to  authorize  its  performance. 

When  neuralgick  sensations  are  traced  from 
just  above  the  angle  of  the  jaw,  in  transverse  lines 
across  the  face,  upwards  through  the  temples5 
downwards  along  the  base  to  the  symphysis  of  the 
chin,  backwards  behind  the  ear ;  exciting  espe- 
cially a  profuse  discharge  of  saliva',  and  fre- 
quently, from  their  severity,  absorbing  all  per- 
ception of  distinct  linear  direction,  but  commu- 
nicating the  idea  of  the  whole  cheek  being  in 
a  paroxysm  of  Neuralgia,  a  surgeon  may  pro- 
nounce the  portio  dura  to  be  the  affected 
nerve. 

A  brief  display  of  the  organs  contained  in  the 
side  of  the  face,  seems  necessary  for  the  purpose 
of  conveying  a  distinct  view  of  the  embarrass- 
ment and  difficulty,  attending  any  projected 
operation  on  the  portio  dura. 

The  parotid  gland,  whose  agency  in  furnish- 

s  I  have  not  noticed  this  in  any  description  of  Neuralgia ;  but  a  moment's 
reflection,  I  think,  will  show,  that  a  diseased  nerve  passing  through  the  paro- 
tid gland,  imbedded  in  its  substance,  must  affect  the  flow  of  saliva  from  that 
gland, 


62 

mg  saliva  is  superior  to  any  other  destined  for 
that  use,  occupies  the  whole  space  from  the 
mastoid  process  of  the  temporal  bone,  pene- 
trating to  the  "  very  root  of  the  external  audi- 
tory sinus,  almost  to  the  internal  carotid  artery 
and  jugular  veinf ;"  it  is  sunk  behind  the  low- 
er jaw,  and  adheres  to  the  pterygoideus  inter- 
nus  muscle,  while  it  reaches  forwardly ,  by  means 
of  the  socia  parotidis,  nearly  to  the  anterior 
edge  of  the  masseter  muscle,  and  upwards  to 
the  zygoma.  The  ducts  from  its  numerous  lo- 
buli  unite,  and  are  continued  in  one  trunk  to  the 
buccinator  muscle,  which  it  perforates  nearly 
opposite  the  second  or  third  dens  molaris.  "  Its 
course  will  generally  be  defined,  by  a  line  ex- 
tended from  the  junction  of  the  lobe  of  the  ear 
and  figured  portion,  to  midway  between  the 
root  of  the  nose,  and  the  angle  of  the  mouth." 

The  arteria  trangversalis  faciei  "  is  generally 
placed  midway  between  the  parotid  duct,  and 
the  zygoma.  At  this  part  it  lies  between  the 
socia  parotidis,  and  the  masseter  muscle." 

"  The  portio  dura,  when  passing  from  the 
foramen  stylo-mastoideum,  lies  behind  the  paro- 
tid gland  ;  but  it  immediately  dips  into  its  sub- 
stance. It  continues  a  single  and  undivided 
trunk,  for  about  half  an  inch  of  its  course.  This 
part  of  the  nerve  runs  in  a  slanting  direction, 
downward  and  forward,  imbedded  in  the  gland. 

t  Surgical  Anatomy  of  the  Head  and  Neck,  by  Mr.  Allan  Burns  of  Glasgow. 


63 

Where  the  portio  dura  is  escaping  from  the 
skull,  it  is  deep  seated,  and  nearly  in  contact 
with  the  arteria  posterior  auris,  and  where  that 
artery  and  the  occipital  arise  by  a  common 
trunk,  the  latter  vessel  is  quite  in  the  vicinity  of 
the  portio  dura.  By  the  styloid  process/' 
(which  is  the  barrier  between  the  external 
and  internal  carotids,)  u  the  nerve  is  sepa- 
rated from  the  internal  carotid  artery,  and 
jugular  vein.  About  midway  between  the 
ascending  plate  of  the  jaw-bone,  and  the  mas- 
toid process,  the  portio  dura  is  nearly  opposite 
to  the  posterior  facial  vein,  and  the  external  ca- 
rotid artery. 

"  It  is  at  this  point,  at  a  place  where  the 
nerve  is  still  deeply  covered  by  the  glandular 
substance,  that  it  divides  into  its  branches, 
which  separately  perforate  the  gland,  to  reach 
the  cheek,  and  other  parts  on  which  they  are 
to  be  distributed.  The  largest  of  these  branches 
inclines  upward  and  forward,  and  while  still 
imbedded  in  the  gland,  it  subdivides  into  a 
numerous  set  of  twigs,  which  cover  as  with  a 
net-work,  the  zygoma  and  the  arteria  transver- 
salis  faciei.  The  largest  of  these  twigs,  runs 
nearly  midway  between  the  zygoma,  and  the 
parotid  duct.  The  other  divisions  of  this  nerve 
ramify  over  the  face,  and  about  the  throat 

"  The  trunk  of  the  nerve  can  be  reached,  with 
safety,  only  by  an  incision  beginning  at  the 


64 

very  root  of  the  mastoid  process,  and  continued 
downward  and  forward,  along  the  anterior 
margin  of  the  sterno-mastoid  muscle.  The 
dissection,  no  doubt,  will  require  to  be  deep, 
but  in  performing  it,  the  surgeon  will  not  ex- 
perience much  difficulty.  The  lobe  of  the  ear 
will  require  to  be  pulled  upward,  and  held  for- 
ward, while  prosecuting  this  dissection.  In  per- 
forming the  dissection,  the  nervus  superficial 
colli  will  necessarily  be  divided,  where  entering 
the  lower  angle  of  the  parotid.  The  glandular 
substance  itself  will  be  injured,  and  the  arteria 
posterior  auris  will  be  cut  across  *." 

In  this  manner,  Mr.  Burns  has  been  in  the 
habit  of  removing  half  an  inch  of  the  nerve  on 
the  dead  subject ;  and  Professor  Mott,  since  the 
inestimable  Surgical  Anatomy  of  the  head  and 
neck  made  its  appearance,  has  exhibited  to  his 
class  of  surgery  the  mode  of  performing  the 
operation.  It  has  never  been  attempted  in  this 
complete  and  radical  manner,  on  the  living 
subject ;  although  many  incisions  have  been 
made  in  the  cheek,  for  the  purpose  of  dividing 
the  branches  of  the  pes  anserinus.  The  outline 
that  has  been  given  of  the  anatomy  of  the  face, 
exhibits  the  difficulty  attending  that  procedure, 
and  the  infallible  consequence  must  be  trou- 
blesome, perhaps  perpetual,  salivary  fistulas. 

Should  it  be  necessary,  however,  to  divide  any 

u  Surgical  Anatomy  of  the  head  and  neck. 


63 

>i»  the  facial  branches  of  the  portio  dura,  it  has 
been  suggested  by  Dr.  Mott,  that  it  might  be 
effected  by  introducing  a  bistoury,  as  in  the 
other  operations,  and  making  the  incisions  in 
various  directions  beneath  the  skin.  The  pros- 
pect  of  an  unpleasant  result  will  be  thus  con= 
siderably  diminished,  and  the  fistula  would  pro- 
bably admit  of  a  more  rapid  cure. 

A  few  observations  on  the  propriety  of  em- 
ploying caustick  applications,  will  close  the  sub- 
ject. If  the  object  be  to  destroy  every  pros- 
pect of  a  recurrence  of  Neuralgia,  and  if  the 
patient  will  consent  to  an  experiment,  which,  if 
successful,  must  effectually  annihilate  the  nerve, 
the  precedents  afforded  by  the  French  surgeons 
will  authorize  the  attempt.  It  has  been  object- 
ed, that  the  proximity  of  some  of  the  nerves  to 
the  bone  must  necessarily  involve  exfoliation. 
This  consequence  depends,  very  probably,  on 
the  management  of  the  caustick,  which  should 
not  be  left  so  long  in  contact  with  the  bone  as 
to  endanger  its  continuity. 

After  the  nerve  has  been  divided  by  the  ope- 
ration, it  may  answer  a  good  purpose  to  inter- 
pose caustick  between  the  extremities  of  the 
nerve,  and  thus  combine  both  expedients.  The 
tediousness  of  reaching  the  nerve  from  the  sur- 
face by  caustick,  besides  the  torture  it  would 
inflict,  possibly  producing  tetanus,  seem  to  in- 

9 


66 

terdict  any  proceeding  different  from  that  propos- 
ed. Dr.  Jones  declined  the  use  of  caustick,  from 
dread  of  tetanus,  nor  was  his  fear  without  foun- 
dation. We  should,  however,  impose  some 
confidence  in  the  practice  of  the  French,  and 
admit  this  method  of  destroying  a  nerve  to  an 
equal  rank  with  the  knife,  in  those  cases  where 
its  employment  is  feasible,  and  unattended  with 
danger  to  the  bone. 


As  the  moment  approaches  in  which  I  shall 
be  endowed  with  the  valuable  privileges  within 
your  gift,  permit  me,  respected  professors, 
to  exercise  the  grateful  office  of  expressing  my 
sense  of  the  obligations  under  which  your  uni- 
form attention  and  kindness  have  placed  me ! 
Lasting  be  the  celebrity  of  the  establishment 
fostered  by  your  exertions,  and  rendered  illus- 
trious by  your  learning— may  its  character 
ever  be  equal  to  its  transcendant  usefulness, 
and  its  patronage  in  proportion  to  its  reputation  ! 
May  the  proud  consciousness  of  honourable 
endeavour  shed  its  delightful  influence  over 
your  declining  years — and  when  the  period 
shall  arrive,  commanding  your  retreat  from  the 
toils  and  distinctions  of  publick  life,  may  your 
successors  emulate  your  brilliant  example,  and 
perpetuate  the  fame  of  our  College  in  the  grati- 
tude of  remote  posterity ! 


APPENDIX. 


In  order  to  complete  the  view  which  has  been  given 
of  Neuralgia,  the  folio  wing  communication  from  Va- 
lentine Mott,  M.  D.  is  subjoined.  It  gives  a  very  sa= 
tisfactory  statement  of  the  consequences  attendant  on 
the  radical  treatment,  and  it  is  the  only  document  of 
that  description  on  record, 

ESTEEMED    PUPIL, 

Since  a  doubt  has  been  expressed  by  some  as 
to  the  eventual  result  of  the  operation  of  dividing  the 
nerve  in  Neuralgia,  allow  me  to  avail  myself  of  this 
opportunity,  to  state  the  success  which  has  attended 
it  in  my  practice. 

In  a  confirmed  case  of  Neuralgia,  in  a  lady  about 
sixty  years  old,  in  1810, 1  divided  the  infra-orbital  nerve 
on  the  right  side ;  the  relief  was  instantaneous.  Be- 
fore the  knife  was  withdrawn,  she  exclaimed,  "  I  am 
relieved,  I  can  now  speak,  blow  my  nose,  and  swal- 
low," which  had  been  almost  impossible  for  some 
days,  owing  to  the  unspeakable  agony  of  the  disease. 
There  were  slight  neuralgic  symptoms  for  about  ten 
days,  then  she  became  perfectly  free  from  the  slightest 
trace  of  it,  and  has  never  since  had  a  return  se- 
vere enough  to  induce  her  to  resort  to  the  operation, 
the  pain  of  which  she  by  no  means  dreads :  for  all  at- 
test that  a  single  paroxysm  far  surpasses  the  smart 
from  the  incision.  For  about  four  months  she  was  en- 
tirely free  from  the  disease. 


68 

A  gentleman  aged  about  fifty,  having  had  Neural- 
gia for  four  years,  applied  to  me,  in  the  beginning  of 
the  year  1811,  for  surgical  relief.  Palliative  means 
having  failed,  and  the  disease  increasing  in  violence,  1 
recommended  the  operation  as  the  best,  and  only  re- 
maining- resource.  I  divided  the  infra-orbital  nerve  of 
his  right  cheek.  The  paroxysms  continued  for  a  day 
or  two  as  frequent  and  violent  as  before  the  operation  : 
but  in  a  week  it  entirely  left  him.  In  about  four 
months,  the  pain  began  to  return,  and  increased  in  vio- 
lence from  time  to  time,  but  did  not  equal  its  former 
severity,  till  about  six  months  since,  when  it  became 
more  severe  than  ever.  About  three  months  ago  I 
repeated  the  operation  on  the  same  nerve :  the  pain 
went  off  gradually  in  about  a  week,  and  he  says  the 
last  operation  is  by  far  the  most  successful. 

In  1811,  I  divided  the  right  infra-orbitary  nerve 
for  a  lady,  who  had  been  labouring  under  severe  Neu- 
ralgia for  two  or  three  years.  She  experienced  no 
immediate  relief;  on  the  contrary,  the  paroxysms  ap- 
peared to  be  increased  in  frequency,  and  aggravated 
in  violence,  for  several  days :  they  then  began  to 
decline,  and  had  entirely  left  her  about  the  twelfth 
day.     1  believe  the  disease  has  never  returned. 

On  that  highly  respectable  physician,  and  victim  to 
Neuralgia,  Dr.  Jones  of  this  city,  I  have  operated 
about  eleven  times,  and  in  every  instance  with  the 
most  perfect  success, 

After  having  been  afflicted  with  this  horrible  disease 
for  seven  or  eight  years,  and  having  exhausted  all  the 
resources  of  the  Materia  Medica  to  no  purpose,  the  Doc- 
tor at  last  yielded  to  my  frequent  and  earnest  impor- 
tunities, and  allowed  me  to  divide  the  right  infra-orbital 


69 

nerve,  at  the  advanced  age  of  sixty-seven  years.  His 
pains  were  increased  for  several  days,  but  about  the 
twelfth  they  abated  gradually,  and  in  a  few  days  com- 
pletely left  him.  He  continued  for  four  or  five  months 
free  from  pain ;  but  after  exposure  to  cold,  he  felt  now 
and  then  alarming  touches  of  the  disease,  which  at 
length  became  very  violent,  Every  subsequent  ope- 
ration on  the  infra-orbital  and  mental  nerves,  has  been 
followed  with  complete  relief;  but  the  intervals  have 
been  mostly  shorter  than  the  first;  they  do  not,  how- 
ever, gradually  shorten  ;  several  of  the  last  operations 
have  varied  very  little  in  the  interval  of  ease,  it  being 
of  from  three  to  four  months  duration. 

The  violence  of  the  paroxysms  has  several  times 
been  augmented  for  a  day  or  two  after  the  operation, 
and  as  the  additional  irritation  of  the  division  of  the 
nerves  subsides,  the  pain  gradually  diminishes.  The 
disease  always  leaves  him  in  from  seven  to  twelve 
days  after  the  operation.  From  the  last  division,  how- 
ever, of  the  infra-orbitary,  about  three  weeks  since, 
he  received  immediate  ease,  having  scarcely  a  single 
pain  afterwards. 

Last  winter,  I  divided  the  right  infra-orbital  nerve 
for  Major  B — ,  aged  about  fifty,  who  had  been  la- 
bouring under  a  regularly  increasing  Neuralgia 
for  about  four  years.  The  operation  increased  his 
disease  in  every  respect  for  several  days ;  it  then  abat- 
ed, and  gradually  went  completely  off  in  about  the 
usual  period  of  twelve  days.  Four  months  and  more 
have  now  elapsed,  and  the  disease  has  not  returned. 

About  three  weeks  since,  I  attended,  in  conjunction 
with  Dr.  Post,  a  Colonel  K — ,  aged  about  sixty,  who 
for  five  years  had  been  afflicted  with  severe  Neuralgia 


70 

of  the  left  infra-orbital  nerve.  Dr.  P.  divided  this 
nerve,  and  it  was  followed  with  immediate  relief.  He 
experienced  little  or  no  pain  afterwards. 

Hoping  that  all  the  miserable  victims  of  Neuralgia 
may  be  encouraged  to  resort  to  a  surgical  operation, 
either  in  the  form  of  a  simple  or  double  division,  by  a 
single  external  incision,  or  where  practicable,  the  re- 
moval of  a  portion  of  the  nerves, 

I  am,  with  sentiments  of  high  regard  and  esteem, 

VALENTINE  MOTT. 

5  mo.  {May)  1st,  181ft     ' 

259  Pearl-st.  New-York. 

The  following  list  of  writers  on  this  disease,  in 
addition  to  those  contained  in  the  body  of  this  disser- 
tation, is  extracted  from  the  Edinburgh  Practice  of 
Physick.  The  impossibility  of  obtaining  them  seems 
to  render  such  a  procedure  necessary,  that  the  occa- 
sional opportunities  of  satisfying  curiosity  on  the  sub- 
ject of  Neuralgia  may  not  be  neglected,  through  want 
of  an  easy  reference. 

Rahn ;  $£ugeum  tier  ^eilftunde,  i.  e.  Museum  of  Me- 
dicine, Vol.  II.  Aepli ;  ibid.  p.  302.  Sauter ;  ibid, 
also  Tissot  and  Pohlen.  Lentin  ;  first  in  Blumenbach's 
Mtbitinigtfyt  SBibliotJjecfe,  i.  e.  Medical  Library,  Vol. 
I.  (A  periodical  work,  that  is  now  discontinued,) 
in  his  Contributions  to  Practical  Medicine,  (in  German,) 
Vol.  I.  1797,  p.  382— -398.  Vol.  II.  1798,  p.  92. 
seq.  Huf eland's  Practical  Journal,  Vol.  IX.  No.  1. 
conf.  Medical  and  Physical  Journal,  Vol.  III.  p.  575. 
Selle;  in  $eue  &eitrage,  frc.  i.  e.  New  Contributions 
to   Natural   and   Medical  Science.   Vol.  I.  p.  27.  &c. 


71 

Vogler  Blumenbach's  Medical  Library,  Vol.  II.  p.  556, 
Thilenius ;  Mtbitinigtbz  una  <Hf)trurgi^ctje  Sfomerfcungen, 
i.  e.  Medical  and  Surgical  Observations,  Franckfort, 
1789.  p.  283.  Bohmer  ;  in  BlumenbacKs  Medic.  Libr, 
Vol.  HI.  p.  315—336.  B aiding er ;  in  his  Medical 
Journal,  Vol.  II.  p.  7.  Lcidenfrost  and  Gunter  ;  in  J.  G. 
Fortsmann  Dissertatio  de  dolore  faciei  Fothergilli, 
Duisburg,  1794,  4to.  extracted  in  Tode's  Medical 
Journal,  (in  German,)  No.  3.  Vol.  I.  Richter  ;  in  his 
Surgical  Library,  Vol-  XI.  p.  135,  (in  German.)  Van 
Wy ;  in  ^Ucjjan&elingen  mtgegetoen  fcoor  Jet  ^eeugtogcfr 
<6enoot^cJap  tier  iBeten?c^appen  te  Wtisgmgen,  l&zu  vii. 
1782.  i.e.  Transactions  of  the  Society  at  Vlissingen? 
Vol.  VII. 

Bonnard;  Journal  de  Medicine,  1778,  July.  Lava- 
gan,  ibid.  Thouret ;  Memoires  de  la  Societe  Royale 
de  Medicine,  a  Paris,  T.  I.  1776.  T.  III.  1779.  T.  V. 
1782  &  83.  Journal  Encyclopedique,  m.  April,  1777, 
Gazette  Salutaire,  No.  73.  conf.  Richter 's  Chirurgical 
Library,  Vol.  II.  in  German.  Andry  ;  Mem.  de  la  Soc. 
Roy.  de  Med.  T.  I.  1776.  T.  V.  1782  &  83.  Guerin  ; 
Maladies  des  Yeux.  Pujol;  Treatise  on  that  disease  of 
the  face,  which  is  called  Tic  douloureux,  translated  from 
the  French  into  German,  by  Dr.  Schreger,  1788. 
Spiehnann  ;  Gazette  Salutaire,  1791.  Petit  and  Lau- 
gier ;  Journal  de  Medicine,  July,  1793.  Watson;  ibid, 
1793,  March,  No.  1. 


FINIS, 


ERRATA. 

Page  f ,  Note, /or  Class  IV.  ii.  6.  read  IV.  i.  ii.  6, 

33,  Line  7,  in  some  copies,  for  contractability  read  con- 
tractility. 


COLUMBIA  UNIVERSITY 

This  bqok  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 


C2e'638)M50 


DATE  BORROWED 


DATE  DUE 


/      fa* 

'-;.!""" J  "  - 

M-HC412         / 
Murray 

*° 

96 


